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19822093-DS-27	19,822,093	26,930,126	DS	27	2149-01-05 00:00:00	2149-01-05 15:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / vancomycin Attending: ___ Chief Complaint: GI bleeding Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: ___ gentleman with past medical history significant for asperger's syndrome, poorly controlled DM2, CKD, CAD (DES to LAD and LCx in ___, HLD, and prior osteomyelitis of his left foot who was recently hospitalized at ___ (___) with DKA and GIB, now re-admitted from rehab after having a melenic stool. On his recent admission, he was found to be in DKA and did have an acute GI bleed with pyloric and duodenal ulcer noted on EGD. He had a 8-point drop in hematocrit and hypotension to the ___ systolic, requiring MICU transfer. He was transfused with 6 units pRBCs and 1 unit FFP. Hemostasis was achieved with acid suppressive therapy, and he was discharged to rehab with plan to repeat EGD 8 weeks post-discharge. Also during that admission, he was also treated for osteomyelitis with nafcillin due to MSSA bacteremia In the ED, initial vitals: 0 98.2 98 109/65 18 99% RA Labs showed: H/H ___ (from 7.9/24.0 on ___ -WBC 8.8, Plt ct ___ -BUN 29 from normal baseline, Cr 1.1 Na 141 k 3.6 Cl 110 HCO3 25 BG 217 He was typed and crossmatched He was given: -IV Pantoprazole 40 mg -1 UNIT of PRBCs GI was consulted and recommended EGD in AM. On transfer, vitals were: 97.8 121/74 97 18 99% RA. On arrival to the floor, the patient was comfortable and had no complaints apart from fatigue. Past Medical History: -asperger syndrome -type II DM, on insulin -CAD (NSTEMI in ___ with DES to LAD and LCx; LVEF estimated 40% on perfusion stress test ___ -CKD, stage III -hyperlipidemia -PVD (peripheral vascular disease) -Left ___ metatarsal partial amputation and left ___ metatarsal amputation ___ -Right foot amputation at tarsal/metatarsal junction ___ -Presumed osteomyelitis of left foot ___, polymicrobial wound infection Strep, serratia, Enterobacter, enterococcus, C septicum, coag negatiev staph. No biospy was performed. TTE performed with no obvious vegetations. Received full 6 wk course of Cipro and Ceftriaxone followed by ___ clinic, completed ___. - osteomyelitis (___), biopsy proven and cultures grew coag-negative staph and corynobacterium, treated with ceftriaxone and flagyl. -Cyst removal from chin ___ years ago) -Depression Social History: ___ Family History: - no family history of DM. - mother with lung cancer Physical Exam: ADMISSION Vitals: 97.8 121/74 97 18 99% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, poor dentition NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: R foot with well-healed transmetatarsal amputation, L foot dressing c/d/i. SKIN: no rash NEURO: moving all extremities DISCHARGE VS98.1 148/80 93 18 98/ra GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, poor dentition NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR NMRG ABD: soft, ntnd. EXT: R foot with well-healed transmetatarsal amputation, L foot dressing c/d/i. SKIN: no rash NEURO: moving all extremities Pertinent Results: ======================= Labs ======================= Admission ___ 01:00PM BLOOD WBC-8.8 RBC-2.34* Hgb-7.0* Hct-21.6* MCV-92 MCH-29.9 MCHC-32.4 RDW-16.1* RDWSD-51.7* Plt ___ ___ 01:00PM BLOOD Glucose-217* UreaN-29* Creat-1.1 Na-141 K-3.6 Cl-110* HCO3-25 AnGap-10 Hgb trend ___ 01:00PM BLOOD WBC-8.8 RBC-2.34* Hgb-7.0* Hct-21.6* MCV-92 MCH-29.9 MCHC-32.4 RDW-16.1* RDWSD-51.7* Plt ___ ___ 07:01PM BLOOD WBC-9.5 RBC-2.72* Hgb-7.8* Hct-24.2* MCV-89 MCH-28.7 MCHC-32.2 RDW-17.6* RDWSD-54.9* Plt ___ ___ 04:19AM BLOOD WBC-8.4 RBC-2.43* Hgb-7.1* Hct-21.8* MCV-90 MCH-29.2 MCHC-32.6 RDW-17.9* RDWSD-57.2* Plt ___ ___ 05:49PM BLOOD WBC-8.3 RBC-3.01* Hgb-8.6* Hct-27.0* MCV-90 MCH-28.6 MCHC-31.9* RDW-17.1* RDWSD-53.4* Plt ___ ___ 04:16AM BLOOD WBC-10.2* RBC-3.09* Hgb-8.9* Hct-27.4* MCV-89 MCH-28.8 MCHC-32.5 RDW-16.8* RDWSD-52.8* Plt ___ ___ 05:20AM BLOOD WBC-6.0 RBC-2.77* Hgb-7.9* Hct-24.9* MCV-90 MCH-28.5 MCHC-31.7* RDW-16.8* RDWSD-53.4* Plt ___ ___ 01:57PM BLOOD WBC-7.7 RBC-2.79* Hgb-8.0* Hct-25.2* MCV-90 MCH-28.7 MCHC-31.7* RDW-16.8* RDWSD-53.3* Plt ___ Urinalysis ___ 06:03PM URINE RBC-1 WBC-50* Bacteri-MANY Yeast-NONE Epi-0 ___ 06:03PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD ___ 06:03PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:15PM URINE RBC-29* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 ___ 01:15PM URINE Blood-MOD Nitrite-POS Protein-30 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG ___ 01:15PM URINE Color-Yellow Appear-Cloudy Sp ___ ======================= Micro ======================= ___ CULTURE-PENDINGINPATIENT ___ CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S)}INPATIENT ___ trachomatis, Nucleic Acid Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINALINPATIENT ___ CULTUREBlood Culture, Routine-PENDINGEMERGENCY WARD ======================= Imaging ======================= ___ CHEST PORTABLE ___ ___ ___ In comparison with the study of ___, the right subclavian PICC line has its tip at about the cavoatrial junction. The Dobhoff tube has been removed. The cardiac silhouette is within normal limits and there is no evidence of vascular congestion or pleural effusion. No definite acute focal pneumonia. ___ Sinus rhythm. Possible inferior myocardial infarction of indeterminate age. Non-specific repolarization abnormalities. Compared to the previous tracing of ___ cardiac rhythm is now sinus mechanism. Otherwise, no diagnostic change. ___ 11:00:00 AM - EGD report Impression: Irregular z-line with heaped up mucosa and severe esophagitis near GE junction. Hematin was seen upon entering the stomach. Diffuse gastritis was seen. A clean-based superficial ulcer was seen upon retroflexion in the fundus. A 2cm clean-based ulcer was seen in the pyloric channel with surrounding heaped up mucosa. Polyp in the fundus Diffuse erythema and congestion seen in the duodenal bulb, consistent with duodenitis. Several clean-based superficial ulcers were seen in D2. Otherwise normal EGD to third part of the duodenum Recommendations: Diffuse ulcer disease likely source of GI bleed. Recommend high dose oral PPI BID x 8 weeks, daily thereafter. Recommend repeat EGD in 8 weeks. Brief Hospital Course: ___ hx asperger's syndrome, poorly controlled DM2, CKD, CAD (DES to LAD and LCx in ___, HLD, and prior osteomyelitis of his left foot who was recently hospitalized at ___ (___) with DKA and GIB, now re-admitted from rehab after having a melenic stool concerning for recurrent UGIB. Course complicated by urinary retention and UTI. # Melena/GIB # Urinary retention # UTI, suspected # left foot osteomyelitis # T2DM # Melena / GI bleed: EGD with stable ulcers and duodenitis. GI to clarify H pylori with pathology. H/H stable. - PO PPI BID x8 weeks # Urinary retention: pt came with foley placed at rehab, for urinary retention per his report. Removed, failed voiding trial, preferred foley to clean intermittent cath. Started tamsulosin 0.4 qhs and finasteride for presumed BPH. Kept Foley in place at discharge with plan for urology f/u as outpt. # UTI, suspected: Patient found to have foul smelling urine, growing GNRs in setting of foley and urinary retention. Could be cause of his urinary retention. - cipro 500 bid x7d (d1 = ___ # left foot osteomyelitis: cont IV nafcillin until ___ per last discharge summary ================== CHRONIC: # T2DM: well controlled on current regimen. cont long acting, HISS, FSG QACHS # CAD: cont ASA, atorvastatin ================== TRANSITIONAL - Needs Urology followup for urinary retention; started on tamsulosin and finasteride - Podiatry: patient has been having trouble getting the special fitted shoes after his TMA - Nafcillin/osteomyelitis: last day ___, does not need further ID follow up Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Citalopram 20 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Nafcillin 2 g IV Q4H 6. Pantoprazole 40 mg PO Q12H 7. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID 8. FoLIC Acid ___ mcg PO DAILY 9. Glargine 18 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Citalopram 20 mg PO DAILY 4. FoLIC Acid ___ mcg PO DAILY 5. Glargine 18 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Nafcillin 2 g IV Q4H Last day ___ 7. Pantoprazole 40 mg PO Q12H For 8 weeks, then per GI. 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days 9. Finasteride 5 mg PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. Fluocinolone Acetonide 0.025% Ointment 1 Appl TP BID 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: # upper GI bleeding secondary to PUD # acute blood loss anemia # urinary retention # urinary tract infection Secondary diagnoses: chronic LLE osteomyelitis DM2 CKD CAD (DES to LAD and LCx in ___ HLD Asperger's syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted for bleeding from your stomach. You had a study (endoscopy) that did not show any obvious new bleeding, but did show some old ulcers. We started you on a medication to decrease your stomach acid; you'll need a repeat endoscopy in 8 weeks. You were also unable to urinate; this caused you to get a urine infection. We placed a catheter, gave you antibiotics for the infection. Please follow up with the Urologists. Please see your appointments and medications below. Sincerely, Your ___ Medicine Team Followup Instructions: ___
19822093-DS-28	19,822,093	22,389,553	DS	28	2149-02-23 00:00:00	2149-02-24 07:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / vancomycin Attending: ___. Chief Complaint: The patient's chief complaint was "I don't want to go back to my rehab facility." Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y.o gentleman with Asperger's syndrome, depression, poorly controlled DM2, CKD stage 3, CAD s/p ___ 2, PVD (s/p partial R foot amputation and L ___ metatarsals), chronic LLE osteomyelitis, recent hospitalization for osteomyelitis, urinary retention (requiring foley placement), and GI bleed -discharged to ___, recently diagnosed with UTI (at rehab, started on ___ for 10day course ___ who presented from GI clinic (where he was for f/u appointment) with agitation and refusal to be transferred back to his rehab (stating he does not like it there and his roommate is noisy), noted to have a positive UA and started on ceftriaxone. During his appointment with GI on ___, he was reportedly quite loud and agitated in clinic. He had many grievances, particularly about the current rehabilitation facility that he has been residing in. He wasoften shouting during his visit with the use of profanities. When he was ready to be picked up by ambulance to return to his facility; he refused to return to the rehab facility. The situation was discussed with Mr. ___ hc proxy who indicated that the patient had full capacity to make decisions. Given a lack of other options, the gastroenterologist decided to refer him to the emergency room such that social work consults could be placed for evaluation and potential placement in an alternate facility. They also hoped that during this ER visit a voiding trial could be attempted. When asked what he doesn't like about his rehab facility he states, "I don't like incompetence but will not elaborate further. He continued to ask me if he has to go back. I spoke with his nurse at ___ where he was residing up until ___ and she said that on the evening of ___, he was more agitated than usual but noted that he often has periods when he is angry and doesn't allow her to check his blood sugar, etc. Regarding his urinary issues, he had urinary retention during his last hospitalization for which he has had a Foley catheter in place since ___ and was due to have this addressed in a clinic visit on ___, however, this did not happen due to transportation mixup. His foley was removed by staff on the day of admission but he was unable to void so another foley was placed. In the ED, due to his refusal to be taken back to rehab, he was held overnight to be evaluated by case management. D/t concern of pt being very agitated, screaming and belligerent to staff, ED doctors decided to obtain labs, urine and found pt to have a UTI and was started on ceftriaxone. In addition to antibiotics, he was given insulin sc, Haldol 5mg, lorazepam 2gm, and 1L normal saline. Regarding his recent hospitalizations, he was recently hospitalized at ___ (___) with DKA and GIB, and then re-admitted (___) from rehab after having a melenic stool. On his earlier admission he was found to be in DKA and did have an acute upper GI bleed with pyloric and duodenal ulcer noted on EGD. He had a 8-point drop in hematocrit and hypotension to the ___ systolic, requiring MICU transfer. He was transfused with 6 units pRBCs and 1 unit FFP. Hemostasis was achieved with acid suppressive therapy, and he was discharged to rehab with plan to repeat EGD 8 weeks post-discharge. Also during that admission, he was also treated for osteomyelitis with nafcillin due to MSSA bacteremia. Hospital course that time was also complicated by urinary retention and UTI. ROS: Remainder of comprehensive 10 point ROS it otherwise negative. Past Medical History: -asperger syndrome -type II DM, on insulin -CAD (NSTEMI in ___ with DES to LAD and LCx; LVEF estimated 40% on perfusion stress test ___ -CKD, stage III -hyperlipidemia -PVD (peripheral vascular disease) -Left ___ metatarsal partial amputation and left ___ metatarsal amputation ___ -Right foot amputation at tarsal/metatarsal junction ___ -Presumed osteomyelitis of left foot ___, polymicrobial wound infection Strep, serratia, Enterobacter, enterococcus, C septicum, coag negatiev staph. No biospy was performed. TTE performed with no obvious vegetations. Received full 6 wk course of Cipro and Ceftriaxone followed by ___ clinic, completed ___. - osteomyelitis (___), biopsy proven and cultures grew coag-negative staph and corynobacterium, treated with ceftriaxone and flagyl. -Cyst removal from chin ___ years ago) -Depression Social History: ___ Family History: - no family history of DM. - mother with lung cancer Physical Exam: VS: 140/83, afebrile, all other vital signs stable GEN: Alert, lying in bed, no acute distress, he is closing his eyes and appears annoyed when I speak to him but he is answering appropriately and follows commands. Oriented to person, place and date/time. Coherent speech. HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS, no suprapubic tenderness GU: foley catheter in place. EXTREM: LUE PICC line looks clean, dry, and intact. Velcro boot on left foot with bandage on left foot that is clean and dry; right foot bandage that is clean and dry NEURO: CN II-XII grossly intact, motor function grossly normal, moving all extremities PSYCH: odd/flat affect Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 01:20PM 6.9 3.47* 9.7* 31.9* 92 28.0 30.4* 13.8 46.3 329 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im ___ AbsLymp AbsMono AbsEos AbsBaso ___ 01:20PM 62.2 23.5 6.9 6.5 0.6 0.3 4.31 1.63 0.48 0.45 0.04 Import Result BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___ ___ 01:20PM 329 Import Result ___ 01:20PM 12.3 30.2 1.1 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 01:20PM 253* 17 1.0 143 3.5 ___ Import Result ESTIMATED GFR (MDRD CALCULATION) estGFR ___ 01:20PM Using this Import Result LAB USE ONLY LtGrnHD ___ 01:20PM HOLD Import Result Blood Gas WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate ___ 01:31PM 2.4* Import Result IMAGING: CXR showed R PICC line had migrated into the axilla. No infiltrates Brief Hospital Course: A/P: Mr. ___ is a ___ y.o gentleman with Asperger's syndrome, depression, poorly controlled DM2, CKD stage 3, CAD s/p ___ 2, PVD (s/p partial R foot amputation and L ___ metatarsals), chronic LLE osteomyelitis, recent hospitalization for osteomyelitis, urinary retention (requiring foley placement), and GI bleed -discharged to STR, presented from ___ clinic (where he was for f/u appointment) with agitation and refusal to be transferred back to his rehab (stating he does not like it there and his roommate is noisy), diagnosed with UTI complicated by ongoing urinary retention after failed voiding trial requiring foley. #Recent GIB: GI had recommended repeat EGD in 8 weeks after recent hospitalization at the end of ___. At this point, he has not since had any significant clinical bleeding per his report and CBC appears stable from last admission. -GI recommended f/u EGD be scheduled within the next 4 weeks, they also recommended checking gastrin level as well as iron studies to assess for ongoing blood loss. -continued BID PPI #Bacterial UTI: was on treatment with PO cipro started at rehab prior to admission since ___ however UA on admission showed ___, -Ni, >182 WBCs, small blood which is suggestive of possible bacterial resistance (however not entirely clear since he has not completed the full course of therapy, 7 days). Last urine culture grew Kleb that was R to nitrofurantoin and I to augmentin (treated with cipro 500 bid x7d (d1 = ___ - Continued Cipro course as before #Urinary retention: pt came with foley placed at rehab, for urinary retention per his report. Removed, failed voiding trial, preferred foley to clean intermittent cath. -Started tamsulosin 0.4 qhs and finasteride for presumed BPH during his last admission. Plan was for urology f/u as outpt. -Dr. ___ knows patient well -continued foley for now #L foot osteomyelitis: he should have completed course of IV nafcillin as of ___ per last discharge summary. followed by Dr. ___ in Podiatry. -pt is currently awaiting custom shoes to be made which is currently be arranged by his podiatrist. #CAD: continued ASA/statin #Depression/Asperger Syndrome: with agitation -agitation may be attributable to UTI and would expect some improvement with treatment to some extent -note that his last d/c summary mentions citalopram 20mg daily however this appears to have been discontinued while at rehab as his med rec (confirmed by me with his rehab facility) did not have citalopram on his list. -consider restarting citalopram 20mg daily #DM: A1c 10.6 ___ -continued home insulin regimen (lantus 24U BID which has been increased while at rehab from 18U BID on last dc summary in ___) + Humalog SS # ACCESS: His R sided PICC line had apparently migrated into the axilla and is not in an appropriate location. A peripheral IV was placed instead. # CODE STATUS: Presumed Full # CONTACT: brother (HCP) ___ ___ cell. I called ___ rehab and confirmed his medication list Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. FoLIC Acid ___ mcg PO DAILY 4. Glargine 24 Units Breakfast Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Finasteride 5 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. Ciprofloxacin HCl 500 mg PO Q12H 8. Gabapentin 100 mg PO QHS 9. Omeprazole 20 mg PO BID 10. Sucralfate 1 gm PO TID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Ciprofloxacin HCl 500 mg PO Q12H ___ay 1 = ___. Finasteride 5 mg PO DAILY 5. Gabapentin 100 mg PO QHS 6. Glargine 24 Units Breakfast Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Omeprazole 20 mg PO BID 8. Sucralfate 1 gm PO TID 9. Tamsulosin 0.4 mg PO QHS 10. FoLIC Acid ___ mcg PO DAILY 11. Acetaminophen 325-650 mg PO Q4H:PRN Pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bacterial UTI Urinary retention h/o Osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted following your GI appointment. Please continue your current plan of care which includes treatment for a UTI and Foley catheter for urinary retention Followup Instructions: ___
19822093-DS-30	19,822,093	22,961,441	DS	30	2149-08-29 00:00:00	2149-08-29 17:57:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / vancomycin Attending: ___. Chief Complaint: Agitation Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx Aspergers, CKD, poorly controlled DM presenting on a section with agitation. He has been increasingly upset with his nursing home with complaints of food and TV issues. He became extremely agitated today, was trying to pull off his wound VAC, pull out his PICC line and he threatened to throw himself down stairs 2 days ago when he was previously seen here. He had returned to the ___ and today continued to be agitated, threatening to pull out his PICC/wound vac. A ___ was placed by ___, MD and he was brought in for evaluation. Had right TMA ___ with wound vac in place. Pt agitated on arrival and yelling but with no medical complaints. Got 1mg Haldol and 2mg Ativan on arrival and was restrained and now is in NAD. Denies alcohol/tobacco/drug use. POD saw him and removed his wound VAC and recommended a few days to let his wound dry before reappling the VAC. Psychiatry was consulted and recommended: no psychiatric contraindication to discharge. Recommend ___ and social work consults. Collateral: ___ from ___ at ___ (___) - Couldn't watch the Olympics on the television (channel 7), . - Staff attempted to accommodate him by giving him an IPad on which to watch the Olympics, but this wasn't working for an unknown reason. - Patient became agitated, stating that the staff lied to him. He began yelling and was not redirectable. - Threatened to leave the facility. When staff advised him that he could not leave because of his medical conditions, he made non-specific threats toward staff (along the lines of "If you don't let me leave, I'm going to do something bad"). No threats of violence. - Believes that the patient is not welcome back at the facility, but this should be verified in the AM by nursing supervisor, ___ (in around 8:00 AM) In the ED, initial vitals were: 97.2 95 123/79 16 100% RA Labs notable for: Hgb 9.5 Serum tox negative Imaging notable for: CXR ___ Right PICC tip in the mid SVC. No acute cardiopulmonary abnormality. Patient was given: ___ 21:32 IV Lorazepam 2 mg ___ ___ 21:32 IV Haloperidol 1 mg ___ ___ 00:05 IV Ampicillin-Sulbactam 3 g ___ ___ ___ 06:00 IV Ampicillin-Sulbactam 3 g ___ ___ ___ 12:12 IV Ampicillin-Sulbactam 3 g ___ ___ 13:25 IM Haloperidol 5 mg ___ ___ 13:25 IV/IM Lorazepam 2 mg ___ ___ 19:00 IV Ampicillin-Sulbactam 3 g ___ Vitals prior to transfer: 0 97.4 84 138/74 16 99% RA ROS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: -asperger syndrome -type II DM, on insulin -CAD (NSTEMI in ___ with DES to LAD and LCx; LVEF estimated 40% on perfusion stress test ___ -CKD, stage III -hyperlipidemia -PVD (peripheral vascular disease) -Left ___ metatarsal partial amputation and left ___ metatarsal amputation ___ -Right foot amputation at tarsal/metatarsal junction ___ -Presumed osteomyelitis of left foot ___, polymicrobial wound infection Strep, serratia, Enterobacter, enterococcus, C septicum, coag negatiev staph. No biospy was performed. TTE performed with no obvious vegetations. Received full 6 wk course of Cipro and Ceftriaxone followed by ___ clinic, completed ___. - osteomyelitis (___), biopsy proven and cultures grew coag-negative staph and corynobacterium, treated with ceftriaxone and flagyl. -Cyst removal from chin ___ years ago) -Depression Social History: ___ Family History: - no family history of DM. - mother with lung cancer Physical Exam: Admission exam: Vital Signs: 97.6 PO 165 / 80 67 18 100 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally anteriorly Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, RL foot wrapped. Neuro: Following commands. Discharge exam: Vital Signs: Afebrile, T 97.1, BP 123/59, HR 64, RR 18, O2 97% RA General: A&Ox3, conversational, lying in bed, comfortable and in NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, no lymphadenopathy CV: Distant heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, right PICC line present without erythema/swelling/TTP Lungs: Clear to auscultation bilaterally Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley, tinea cruris present diffusely in the groin folds but improving, appears erythematous and moist, no condom cath Ext: Warm, well perfused, 2+ pulses, R foot plantar surface has dried blood and wound vac applied, L foot appears clean s/p TMA. Neuro: AOx3, non-focal, following commands. Pertinent Results: Admission labs: ___ 11:40PM BLOOD WBC-6.1 RBC-3.40* Hgb-9.5* Hct-31.1* MCV-92 MCH-27.9 MCHC-30.5* RDW-14.6 RDWSD-49.1* Plt ___ ___ 11:40PM BLOOD Neuts-56.5 ___ Monos-9.0 Eos-8.3* Baso-0.5 Im ___ AbsNeut-3.45 AbsLymp-1.55 AbsMono-0.55 AbsEos-0.51 AbsBaso-0.03 ___ 11:40PM BLOOD Glucose-219* UreaN-27* Creat-1.0 Na-140 K-3.3 Cl-107 HCO3-26 AnGap-10 ___ 05:31AM BLOOD Albumin-3.2* Calcium-9.3 Phos-3.1 Mg-1.8 Pertinent labs: ___ 05:00AM BLOOD Free T4-1.2 ___ 05:00AM BLOOD TSH-1.3 ___ 05:31AM BLOOD VitB12-519 ___ 05:31AM BLOOD ALT-21 AST-15 LD(LDH)-114 AlkPhos-91 TotBili-0.4 Discharge labs: ___ 05:47AM BLOOD WBC-5.0 RBC-3.62* Hgb-10.3* Hct-33.6* MCV-93 MCH-28.5 MCHC-30.7* RDW-15.0 RDWSD-51.5* Plt ___ ___ 05:47AM BLOOD Glucose-80 UreaN-21* Creat-1.0 Na-140 K-4.2 Cl-103 HCO3-26 AnGap-15 ___ 05:47AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ y/o male with autism spectrum disorder, peripheral vascular disease, type 2 DM on insulin, and chronic osteomyelitis of the right foot s/p TMA on ___ and s/p Unasyn IV x6 weeks who presents from a rehab facility due to agitation and conflicts with the staff. #Agitation: Patient was agitated on arrival, but he is easily redirectable. Review of old Atrius records reveals that patient has had a long-standing history of acting out behavioral events, so his current episodes are likely not due to any new pathology. Infectious and toxic metabolic workup on admission were negative for any new infections or metabolic abnormalities. He was evaluated by our psychiatry team who recommended Depakote 250 mg PO BID for mood stabilization and Seroquel 25 mg po BID prn for agitation. He has done well with this regimen. Psychiatry also believed that he does not have decision-making capacity to leave AMA, but this will need to be reevaluated if it again becomes an issue. We also discussed with his HCP ___ and ___, who both agreed that this current mental status is similar to how he has been in the past. We had several conversations with his HCP and friend, and they explained that Mr. ___ is very particular about his living situation. There are several things that are important to him including food that he likes and a functional TV with the correct channels. His HCP will be returning to the US on ___ and will be able to visit and assist with the patient's care and decision-making. #Chronic osteomyelitis of right foot: He is s/p TMA on ___ and was started on 6 weeks of IV Unasyn with a PICC line. His 6 week course of Unasyn ended on ___ without complications. He denies any pain in his foot or infectious symptoms, and his vital signs have remained stable throughout. He was evaluated by our ID and podiatry teams, who felt no new changes had to be made. His wound vac was changed every 3 days, and he is to continue non weight-bearing on the right foot until clearance from podiatry. His PICC was removed prior to discharge. He will see Dr. ___ 1 week after discharge for follow-up. There is no further indication for antibiotics at this time. #Tinea cruris: He was found to have diffuse tinea cruris in the groin folds and was started on miconazole powder BID, with good improvement. He should continue this until the infection has improved. CHRONIC ISSUES: # Type 2 DM: Continued home insulin with slight change (Lantus 20U breakfast and bedtime, along with Humalog ISS) # CAD s/p DES: Continued ASA 81 mg daily, Atorva 80 mg daily, Metoprolol 50 mg daily # Constipation: Continued miralax # PUD: Continued ranitidine 150 mg daily, sucralfate 1g PO TID # Chronic pain: Continued gabapentin 100 mg PO qhs, continue oxycodone 5 mg PO q6h prn pain # BPH: Continued finasteride and tamsulosin Transitional issues: - F/up with Dr. ___ in 1 week. Please schedule by calling the number listed ___, ___ ___ - Change wound vac every 3 days - Non weight-bearing on right leg until wound fully heals and cleared by podiatry - PICC removed on ___, no acute indication for lab monitoring - Psych meds: Continue Lexapro 20 mg PO daily for depression, Depakote 250 mg PO BID for agitation, and Seroquel 25 mg PO BID prn agitation - Insulin regimen: Levemir 24 U at breakfast and 24 U at bedtime, along with insulin sliding scale # CODE: FULL # CONTACT NUMBERS: - Brother ___ ___, who lives in ___ - Friend ___ ___ - Friend and HCP ___ ___ or cell phone (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 100 mg PO QHS 2. Escitalopram Oxalate 10 mg PO DAILY 3. Ampicillin-Sulbactam 3 g IV Q6H 4. Finasteride 5 mg PO DAILY 5. Ranitidine 150 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Polyethylene Glycol 17 g PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Aspirin 81 mg PO DAILY 10. Levemir 24 Units Breakfast Levemir 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Sucralfate 1 gm PO TID 12. Atorvastatin 80 mg PO QPM 13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 14. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Divalproex (DELayed Release) 250 mg PO BID 2. Miconazole Powder 2% 1 Appl TP BID 3. QUEtiapine Fumarate 25 mg PO BID:PRN agitation 4. Escitalopram Oxalate 20 mg PO DAILY 5. Levemir 24 Units Breakfast Levemir 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Finasteride 5 mg PO DAILY 9. Gabapentin 100 mg PO QHS 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Ranitidine 150 mg PO DAILY 14. Sucralfate 1 gm PO TID 15. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Agitation Chronic osteomyelitis of right foot Secondary diagnosis: Tinea cruris Depression Type 2 Diabetes Mellitus CAD Peptic ulcer disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to ___ due to agitation with the living situation at your prior rehabilitation facility. You were evaluated with lab tests and started on one medication to assist your mood. You were also seen by our podiatry, infectious disease, and psychiatry teams. Your antibiotic course for your right foot infection ended on ___. We have been changing your wound vacuum every three days, which should continue. You will see Dr. ___ podiatrist, as an outpatient in one week for follow-up. Followup Instructions: ___
19822093-DS-31	19,822,093	25,670,709	DS	31	2150-01-29 00:00:00	2150-01-29 17:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / vancomycin Attending: ___ Chief Complaint: failure to thrive: difficulty with ambulation and concern for unsafe living environment. Major Surgical or Invasive Procedure: none History of Present Illness: ___ hx of bilateral transmetatarsal amputation, peripheral vascular disease, diabetes, and here for concern for decreased safety at home by home ___ service and reportedly symptomatic BP of 74/50. Hx of Asperger's so history slightly limited. However, patient reports everyone says "it is not safe for him to be at home but this is bullshit." Per online records: ___ reported R foot plantar aspect with new skin breakdown, 1.5 cm x 1.5 cm area is "red and angry" with slight thick drainage, afebrile and NP called in Keflex ___ mg PO BID x 7 days to ___. At 12:30 on ___ patient had BP of 74/50 and was symptomatic. Patient does not report this. Additionally, Comment: ___ RN called at 2:00 pm to report pt has R foot plantar aspect with new skin breakdown, 1.5 cm x 1.5 cm area is "red and angry" with slight thick drainage, afebrile. ___ recommended ER, pt declined and stated that he had no way to get to ___. Patient was brought to ED. Per report, current ___ service will not take patient back at this time. Patient nonambulatory at baseline using wheelchair and lift to get up to second floor residence, only able to stand and transfer with difficulty. Patient without any acute complaints at this time. - In the ED, initial vitals were: T 96.2 HR 96 BP 94/64 RR 20 98% RA - Exam notable for right foot with diabetic ulcer under R ___ metatarsal, without signs of acute infection or spreading erythema, CTAB, Abd soft, NT, ND. - Labs notable for WBC 7.9, H/H 11.0/34.4, albumin 3.3, Cr 1.4 (Cr 1.0 in ___. UA was notable for large leuks, pyuria WBC > 182. - CXR was unremarkable - In ED, the patient received: Cefriaxone 1 g IV x1 and IV NS. - ___ evaluated patient who felt him unsafe for discharge home, Psychiatry was also consulted who deferred psych admission - Decision was made to admit patient to medicine for failure to thrive, ___, and UTI - Transfer VS were: T 98.0 HR 99 BP 125/52 RR 18 SpO2 100% RA On arrival to the floor, patient reports right foot pain. No fever/chills, no cough. Denies poor po intake, vomiting/diarrhea. Additionally no dysura, suprapubic pain or back pain. ROS: As per HPI, otherwise negative in detail Past Medical History: - Asperger syndrome - type II DM, on insulin - CAD (NSTEMI in ___ with DES to LAD and LCx; LVEF estimated 40% on perfusion stress test ___ - CKD, stage III - hyperlipidemia - PVD (peripheral vascular disease) - left ___ metatarsal partial amputation and left ___ metatarsal amputation ___ - right foot amputation at tarsal/metatarsal junction ___ - presumed osteomyelitis of left foot ___, polymicrobial wound infection Strep, serratia, Enterobacter, enterococcus, C septicum, coag negatiev staph. No biospy was performed. TTE performed with no obvious vegetations. Received full 6 wk course of Cipro and Ceftriaxone followed by ___ clinic, completed ___. - osteomyelitis (___), biopsy proven and cultures grew coag-negative staph and corynobacterium, treated with ceftriaxone and flagyl. - cyst removal from chin ___ years ago) - depression Social History: ___ Family History: - no family history of DM. - mother with lung cancer Physical Exam: ADMISSION PHYSICAL EXAM ================================ VS: 98.1 PO 138 / 72 88 18 99 RA General: Alert, oriented, no acute distress, easily agitated but redirectable, tangential HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Bilateral TMA right foot has 2 eschars on plantar surface, ~1cm over ___ digit, mild surrounding erythma no discharge nor induration. Pulses 1+ Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Psych: poor insight, denies anhedonia, SI/HI DISCHARGE PHYSICAL EXAM ================================ Vitals: 97.4 PO BP: 163/78 HR: 74 RR: 16 SO2: 98 RA General: Alert, oriented, no acute distress, easily agitated but redirectable, tangential HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Bilateral TMA right foot betadine dressing C/D/I over 1cm by 1cm eschar. TA pulses 1+ Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. Pertinent Results: ================================ ADMISSION LABS ================================ ___ 06:20PM BLOOD WBC-7.9# RBC-3.70* Hgb-11.0* Hct-34.4* MCV-93 MCH-29.7 MCHC-32.0 RDW-13.4 RDWSD-45.3 Plt ___ ___ 06:20PM BLOOD Neuts-77.8* Lymphs-10.3* Monos-10.8 Eos-0.5* Baso-0.3 Im ___ AbsNeut-6.16# AbsLymp-0.81 AbsMono-0.85* AbsEos-0.04 AbsBaso-0.02 ___ 06:20PM BLOOD Glucose-246* UreaN-36* Creat-1.4* Na-139 K-3.3 Cl-102 HCO3-22 AnGap-18 ___ 06:20PM BLOOD Albumin-3.3* ___ Urinalysis: Color: Yellow Appearance: Cloudy Specific Gravity: 1.022 Blood: Small Nitrite Neg Protein 100 Glucose 150 Ketone 10 Bilirubin: negative RBC: 5 WBC: > 182 Bacteria: Many ================================ KEY INTERVAL LABS ================================ ___ 06:40AM BLOOD WBC-7.2 RBC-3.54* Hgb-10.4* Hct-33.0* MCV-93 MCH-29.4 MCHC-31.5* RDW-13.2 RDWSD-45.4 Plt ___ ___ 06:40AM BLOOD Glucose-193* UreaN-23* Creat-0.9 Na-140 K-4.1 Cl-104 HCO3-28 AnGap-12 ___ 06:40AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 ___ 06:30AM BLOOD CRP-37.7* ================================ KEY IMAGING ================================ MR FOOT ___ CONTRAST RIGHT ___: The study is limited due to patient motion and susceptibility artifacts. There are no obvious signs of osteomyelitis and no rim enhancing fluid collections. Multiple patchy areas of bone marrow edema with mild enhancement are not adjacent to soft tissue ulcers, and are unlikely to represent osteomyelitis. In addition, the T1 marrow signal appears preserved. C SPINE NONTRAUMA ___ VIEWS ___: FINDINGS: C1 through C6 are demonstrated on lateral view. No prevertebral swelling is identified. Cervical lordosis is preserved. Vertebral body and disc heights are preserved. No fracture or spondylolisthesis is detected. No suspicious lytic or sclerotic lesion is identified. The lateral masses are symmetric about the dens. No radiopaque foreign body. Surgical clips project over the upper extremity. IMPRESSION: No radiopaque foreign body. DX THORACIC AND LUMBAR SPINE X-RAY ___ : 5 non-rib-bearing lumbar vertebral bodies are present. Vertebral body and disc heights are preserved. No fracture or dislocation. Anterior bridging osteophytes are noted at multiple levels. No suspicious lytic or sclerotic lesion is identified. Severe degenerative changes are seen in the bilateral femoroacetabular joints. No radiopaque foreign body. IMPRESSION: No dorsal radiopaque foreign body. ARTRERIAL DOPLLE REXAM (REST ONLY) ___: Doppler waveform analysis reveals triphasic waveforms at the right common femoral and superficial femoral arteries with monophasic waveforms at the right popliteal, posterior tibial, and dorsalis pedis. Waveforms are triphasic at the left common femoral and superficial femoral arteries, and biphasic at the popliteal, posterior tibial and dorsalis pedis. Ankle-brachial indices could not be obtained due to noncompressible vessels. Pulse volume recordings demonstrate mild dampening at the right thigh there is significant dampening at the right calf and only minimal deflection at the right ankle. Waveforms are normal throughout the left lower extremity. IMPRESSION: Significant right popliteal and tibial arterial disease ================================ MICROBIOLOGY ================================ ___ BLOOD CULTURE: Negative ___ BLOOD CULTURE: Negative ___ BLOOD CULTURE: Negative ___ URINE CULTURE: BETA STREPTOCOCCUS GROUP B Brief Hospital Course: ___ year old man with history of bilateral transmetatarsal amputation, peripheral arterial disease, diabetes mellitus type 2 who presented to ___ ED with concern for decreased safety at home by home ___ service and was found to have acute kidney injury, right lower extremity cellulitis and orthostatic hypotension with supine hypertension. #orthostasis: in setting of supine hypertension. Asymptomatic without dizziness, lightheadedness, chest pain or shortness of breath. Not fluid responsive, most likely multifactorial with autonomic neuropathy in setting of poorly controlled DM and medication effect secondary to metoprolol, tamsulosin. We discussed the risks and benefits of stopping metoprolol with both Mr. ___ and his healthcare proxy Mr. ___. At discharge we will continue trial of fludrocortisone 0.2 mg daily which allows SBP to remain above 90 with position changes. Mr. ___ would benefit from continued optimization of this regimen. He may need nighttime calcium channel blocker once orthostasis optimized or outpatient ___ clinic evaluation (___). On day of discharge, standing BP of more than 110 and he is asymptomatic. # Failure to Thrive: Sent to ___ ED for inability to ambulate at home by ___. Physical therapy recommended rehabilitation, patient not amenable. Given patient and health care proxy's refusal for rehabilitation, current goal was to maximize home services for 24hr care until Mr. ___ can find suitable long-term nursing facility via ___. # Right foot cellulitis # Bilateral Transmetatarsal Amputation, Eschar, Skin breakdown: surrounding area of erythema around right foot exhar. Most concerning for cellulitis given no prurlence and small size of erythema did not cover for MRSA. Podiatry was consulted: x-ray without sign of chronic osteomyeltitis (low concern for acute). Repeat arterial studies show significant right popliteal and tibial arterial disease. MRI of right foot without signs of osteomyelitis. He completed 10 days of antibiotics ___. He will follow-up with podiatry as outpatient. ============================= CHRONIC ISSUES: ============================= # Type 2 Diabetes Mellitus: Patient administers insulin at home and has done so for years. He is able to articulate what he should do if he thinks his blood sugar is low or if he is sick and not eating. During this admission he had an episode of fasting hypoglycemia so lantus dose was decreased to 22units BID. If patient amenable as outpatient a sliding scale may be helpful. # Coronary Artery Disease s/p drug eluting stent: Continued home ASA 81 mg daily, Atorvastatin 80 mg daily. Metoprolol was discontinued secondary to continued orthostasis. # Constipation: Continued home miralax # Peptic ulcer disease: Continued home ranitidine 150 mg daily # Chronic pain: Continued home gabapentin 100 mg PO qhs # Benign Prostatic Hypertrophy: Continue home finasteride. Tamsulosin was held in setting of orthostatic hypotension. ============================= RESOLVED ISSUES ============================= # Acute Kidney Injury: Creatinine was 1.4 on admission and returned to baseline of 1.0-1.1 (similar to ___ with intravenous fluid. Likely represented pre-renal azotemia in setting of poor PO intake given Bun:Crt >2 and rapid improvement. # Urinary Tract Infection: UA grossly positive in ED but Ucx with GBS. Patient received five days ceftriaxone ending on ___. Patient did complete ten day course of antibiotics with augmentin for cellulitis which likely provided additional coverage. # h/o of foreign metallic body: Both patient and healthcare proxy report "pin in back" from unknown source. Spine x-rays without radio-opaque foreign body. Patient tolerated MRI this admission without incident ============================= TRANSITIONAL ISSUES ============================= DISCONTINUED MEDICATIONS: metoprolol, tamsulosin NEW MEDICATIONS: fludracortisone 0.2mg daily [ ] continue to titrate fludacortisone as needed [ ] consider graded compression stockings (discharged with ___ compression stockings), abdominal binder, nighttime calcium channel blocker once orthostasis optimized or outpatient ___ clinic evaluation (___) [ ] assess ability to restart metoprolol if orthostasis improves [ ] Decreased lantus to 22units BID due to episode of fasting hypoglycemia. Consider insulin sliding scale at meal times if Mr. ___ is willing [ ] wound care: betadine wet to dry dressing daily [ ] weight bearing as tolerated [ ] follow-up with podiatry as scheduled [ ] follow-up with PCP as scheduled DIscussion regarding his disposition: a summary from prior notes At this point Mr ___ and HCP are refusing SNF/LTAC requesting discharge home. Although Mr ___ does not have capacity to make this decision (unable to articulate risks/consequences of going home with inadequate supervision) his HCP ___ is able to. He understands Mr ___ is at risk of falls, infection, poor hygiene, and death unable to adequately care for himself independently and unable to self-pay for additional care; however, Mr ___ justifies that he is willing to accept these risks on Mr ___ behalf due to the emotional distress and regression it will place him under returning to ___ at this time. Despite recommendations from the medical team, case management, social work, ___ services, ___, and psychiatry that Mr ___ needs more assistance at home, which neither we nor self-pay can provide, Mr ___ continues to accept the risk of going home. At this point he wants to give Mr ___ one last try on his own, and if he fails will proceed with LTAC placement at that time. As per legal counsel we cannot overturn the HCP's decision, even though we advise against it, unless we feel there is immediate and grave danger or he is not doing what he believes is in the patient's best interest. Despite the risks of going home there is not a compelling enough grave or immediate danger that would force us to overturn patient's HCP. At this point recommend optimizing the safest discharge home with maximizing and distributing ___ services over as many days of the week as possible, requesting assistance from Mr ___ to fill in the gaps, and additional DME in the house. Given the frequent ___ visits they can quickly assess and intervene if patient is failing at home and currently at risk for infection or unacceptable states of hygiene. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Escitalopram Oxalate 20 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY 6. Ranitidine 150 mg PO DAILY 7. Tamsulosin 0.4 mg PO QHS 8. Divalproex (DELayed Release) 250 mg PO DAILY 9. Miconazole Powder 2% 1 Appl TP BID 10. Multivitamins 1 TAB PO DAILY 11. QUEtiapine Fumarate 25 mg PO BID:PRN agitation 12. Glargine 24 Units Breakfast Glargine 24 Units Bedtime 13. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Fludrocortisone Acetate 0.2 mg PO DAILY RX fludrocortisone 0.1 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:*0 2. Glargine 22 Units Breakfast Glargine 22 Units Bedtime 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Divalproex (DELayed Release) 250 mg PO DAILY 6. Escitalopram Oxalate 20 mg PO DAILY 7. Finasteride 5 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. QUEtiapine Fumarate 25 mg PO BID:PRN agitation 10. Ranitidine 150 mg PO DAILY 11.Wheelchair ICD 10: I95.1 Prognosis: Good ___: 13 months 12.Hospital Bed ICD 10: I95.1 Prognosis: Good ___ 13 months Patient is room confined 13.Bedside Commode ICD 10: I95.1 Prognosis: Good ___: 13 months Patient is room confined Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Orthostatic Hypotension SECONDARY DIAGNOSES Failure to thrive Cellulitis Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with acute kidney injury, a skin infection of your right foot and difficulty walking. While you were here you received antibiotics, were evaluated by podiatry and worked with physical therapy. We also increased your nursing services available at home. It was a pleasure taking care of you! -Your ___ Team Followup Instructions: ___
19822093-DS-32	19,822,093	22,476,742	DS	32	2150-06-04 00:00:00	2150-06-04 16:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril / vancomycin Attending: ___ Chief Complaint: Right foot ulcer Major Surgical or Invasive Procedure: ___: Diagnostic Right lower extremity angiogram ___: Right superficial femoral artery and popliteal angioplasty and stent placement x3. History of Present Illness: ___ year old man with history of bilateral transmetatarsal amputation, PAD, T2DM presenting with R foot pain. He reports that he has been having more pain at his wound site for the past ___ weeks. He denies definite increase ___ drainage from the wound. He reports that "it feels infected". Notably, he has home wound care that has been coming once a day to change his wound dressings. He denies fevers or chills. He was admitted ___ the ___ for sepsis related to this foot wound. He was taken to the OR for debridement and bone cx was positive for osteomyelitis. Culture grew coagulase negative Staph and pan sensitive enterococcus, eventually treated with 6 weeks of amp/sulbactam. ___ the ED, initial vitals were: 97.5 102 118/78 17 98% RA - Exam notable for: Black eschar on R foot with minimal purulence at the edge. No fluctuance. Minimal erythema around the eschar. Also has 2 punctate wounds on medial surface, one of which is packed. Probes to bone. - Labs notable for: WBC 7.5, CO2 21 - Imaging was notable for: R ___ metatarsal changes c/f osteomyelitis - Patient was given: ___ 00:04 PO Lorazepam 1 mg REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above ___ HPI Past Medical History: - Asperger syndrome - type II DM, on insulin - CAD (NSTEMI ___ ___ with DES to LAD and LCx; LVEF estimated 40% on perfusion stress test ___ - CKD, stage III - hyperlipidemia - PVD (peripheral vascular disease) - left ___ metatarsal partial amputation and left ___ metatarsal amputation ___ - right foot amputation at tarsal/metatarsal junction ___ - presumed osteomyelitis of left foot ___, polymicrobial wound infection Strep, serratia, Enterobacter, enterococcus, C septicum, coag negatiev staph. No biospy was performed. TTE performed with no obvious vegetations. Received full 6 wk course of Cipro and Ceftriaxone followed by ___ clinic, completed ___. - osteomyelitis (___), biopsy proven and cultures grew coag-negative staph and corynobacterium, treated with ceftriaxone and flagyl. - cyst removal from chin ___ years ago) - depression Social History: ___ Family History: - no family history of DM. - mother with lung cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 98.4 155/84 84 20 96% RA General: Alert, oriented, no acute distress, speaking softly HEENT: PERRL, sclerae anicteric, MMM, oropharynx clear CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended Ext: Bilateral TMAs, right with 3 x 3 area of eschar over medial aspect, smaller 1x1 area of bloody drainage on lateral edge with minimal surrounding erythema Skin: no suspicious rashes or lesions noted DISCHARGE PHYSICAL EXAM: VS: 97.4 PO 109 / 71 76 18 99 RA GENERAL: chronically ill-appearing man, NAD, slow to answer some questions HEENT: anicteric sclera, poor dentition HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: non-labored breathing on RA, CTAB ABDOMEN: soft, NT, ND EXTREMITIES: gross muscle atrophy bilaterally, L foot with no toes, R foot covered with c/d/I dressing NEURO: Isolated Left CN 6 palsy, unable to abduct (old); increased tone with spasticity ___ legs SKIN: no significant rashes Pertinent Results: ============== ADMISSION LABS ============== ___ 08:20PM BLOOD WBC-7.5 RBC-4.13* Hgb-11.8* Hct-40.5 MCV-98 MCH-28.6 MCHC-29.1* RDW-12.7 RDWSD-46.2 Plt ___ ___ 08:20PM BLOOD Neuts-63.7 ___ Monos-10.3 Eos-1.6 Baso-0.5 Im ___ AbsNeut-4.76 AbsLymp-1.76 AbsMono-0.77 AbsEos-0.12 AbsBaso-0.04 ___ 08:20PM BLOOD Glucose-275* UreaN-24* Creat-1.2 Na-137 K-3.3 Cl-96 HCO3-21* AnGap-23* ___ 06:54AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9 ======================= PERTINENT INTERVAL LABS ======================= ___ 09:34AM BLOOD %HbA1c-7.3* eAG-163* ___ 08:20PM BLOOD CRP-127.5* ___ 08:15AM BLOOD CRP-59.4* ___ 07:35AM BLOOD CRP-36.5* ============== MICROBIOLOGY ============== ___ 6:18 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 3:14 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. 3+ ___ per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. YEAST. MODERATE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S __________________________________________________________ ___ 12:50 am BLOOD CULTURE Source: Venipuncture 2 OF 2 . FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 12:40 am BLOOD CULTURE Source: Line-CVL. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 9:48 am URINE Source: Catheter. *FINAL REPORT ___ URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ENTEROCOCCUS SP.. >100,000 CFU/mL. CIPROFLOXACIN AND DOXYCYCLINE Sensitivity testing per ___ (___) ___. DOXYCYCLINE = RESISTANT. DOXYCYCLINE sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R CIPROFLOXACIN--------- =>8 R NITROFURANTOIN-------- 256 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=0.5 S ============== IMAGING ============== Foot x-ray ___: Finding as above raise potential concern for subtle osteomyelitis just deep to the plantar ulcer. Linear densities within the soft tissues, question foreign body versus surgical material. Arterial studies ___: Patent right fem-pop bypass graft without significant stenosis. ___ NCHCT FINDINGS: There is no evidence of acute infarctionhemorrhage,edema,or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There are several areas of encephalomalacia ___ the right frontal, right occipital, and right parietal lobes, stable from prior exam. Hypodensity ___ the left basal ganglia is again seen and may also represent old lacunar infarct. There is no evidence of fracture. The left sphenoid sinus is opacified. The mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Atherosclerotic calcification of the carotid siphons are noted. ___ CTA HEAD AND NECK IMPRESSION: 1. Occlusion of the right internal carotid artery from its origin to the level of the clinoid ICA with collateral filling the right middle and anterior cerebral arteries. 2. Mild stenosis of the right common carotid artery at its origin. 3. Opacities of the right upper lobe of the lung representing atelectasis versus aspiration ___ MRI Head IMPRESSION: 1. Multiple chronic infarcts as described above without evidence of acute infarction. No hemorrhage. 2. Known occlusion of the right internal carotid artery with reconstitution of flow ___ the supraclinoid segment and more distal branches. 3. Paranasal sinus inflammatory changes. ___ CXR IMPRESSION: ___ comparison with study of ___, there is no evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. The Dobhoff tube is been removed. ============== DISCHARGE LABS ============== None checked, pt stable Brief Hospital Course: BRIEF SUMMARY ============= ___ year old man with history of bilateral transmetatarsal amputation, PAD, T2DM presenting for osteomyelitis of ___ R metatarsal. Pt underwent vascular procedure on RLE as below without complications. His discharge was unfortunately significantly held up by insurance issues. He subsequently suffered an acute neurologic event, likely a seizure precipitated by a UTI, that prolonged his stay further. He ultimately returned to baseline after a brief stay ___ the neuro ICU as below. PROBLEM-BASED COURSE ==================== # R fifth metatarsal Osteomyelitis: Pt with history of chronic wound p/w new ulcer on lateral aspect of right foot that probed to bone. Diagnosed with osteomyelitis based on XR evidence and clinical exam. CRP also markedly elevated to 127.5 on admission. ED wound cultures grew pan-sensitive pseudomonas. Non-invasive vascular studies were inconclusive regarding the patency of his existing graft. Further, the surgical teams noted increased pus from his right foot ulcer and felt further interventions were necessary. He was started on empiric coverage with daptomycin, cefepime, and flagyl given a history of enterobacter and his care was transitioned to the vascular surgery service. Infectious disease was consulted who recommended cefepime (IV) and flagyl as appropriate antibiotic coverage for cultures, and recommended levofloxacin (PO) and flagyl if patient were to refuse IV antibiotics, as he had done during previous admissions. On ___ he underwent RLE angiogram, which showed occlusion of the AK-popliteal-to-AT bypass graft. He then underwent a R SFA/pop PTA/stent via retrograde AT access on ___. For the remainder of his stay he had several bedside debridements with podiatry with routine wound care. He finished a 6 week course of cefepime/flagyl, as well as 30 days of Plavix. No antibiotics or Plavix required on discharge. #Capacity: the patient has a known (and well-documented) history of non-compliance and disagreement with medical recommendations regarding his care, and thus was followed by pyschiatry, social work and complex case management throughout the course of his hospitalization to facilitate goals of care discussion. Capacity is a situation-dependent evaluation and the patient was evaluated by psychiatry as needed throughout his hospitalization. He was deemed to have capacity, and he agreed with proceeding with anigogram on ___. #Seizure: (Neuro ICU Course ___ - ___ On ___, the patient's nurses called ___ code because he was found to be unresponsive. He did have a pulse. He was mildly hypoxemic briefly, and was having multiple episodes of emesis. On evaluation of the patient, he was somnolent but arousable, not able to answer questions or follow commands. The patient was transferred to the CVICU where he was evaluated by the neurology team who was concerned for possible stroke based on exam. Head CT showed unclear aged stroke. Neuro was concerned about possible seizure focus leading to status epilepticus vs. a new brainstem stroke. He was intubated for airway protection, and was subsequently transferred to the Neuro-ICU for further care. A CTA revealed likely a chronically occluded right ICA, and a hypoplastic right vertebral artery, but no major vessel occlusions. A subsequent MRI did not show evidence of acute infarction. He was monitored on cvEEG which did not show seizures. He was weaned to extubation on ___. Infectious work up revealed a urinalysis concerning for a urinary tract infection, though no organism was identified. No clear etiology was identified for his sudden change ___ clinical status, although the leading possibility was that the urinary tract infection led to a decreased seizure threshold, with his previous stroke factor as a possible nidus for his seizure. His home Depakote, which he had been taking for mood issues, was increased for seizure prevention. Other possibilities were explored, including toxic ingestion (negative tox screen), medication effect (no significant medication changes around the time of the event). Regarding his stroke risk factors, he was continued on ASA and atorvastatin. #UTI: As above, it was thought that UTI could have potentially triggered above seizure. UA with large leuks, WBC >182 although nitrites negative. ___ urine culture negative, and patient was started on CTX given possible provocation of seizure by UTI. Completed 7 day course. Patient had an issue with urinary retention requiring foley insertion and initiation of finasteride, but subsequently passed voiding trial and foley was removed. Pt had a subsequent urine culture that grew enterococcus, but sample was contaminated and pt was asymptomatic without fevers or elevated white count, elected not to treat. ___ the future, if the patient requires catheter placement, begin with a ___ coude catheter. There was minimal resistance with this sized catheter. #Nutriton: Because of poor PO intake, pt was initiated on tube feeds to supplement caloric intake. The nutrition teamed followed the patient and provided ongoing recommendations. His diet was ultimately advanced to thin liquids and soft solids on discharge. # Type 2 Diabetes Mellitus: Initially continued home 22U glargine qAM and QHS with SSI. Because of poor glycemic control, the ___ diabetes team was consulted and made adjustments to his insulin regimen. When he initiated tube feeds, he was put on a regular insulin sliding scale. On discharge, his insulin regimen consisted of 22U glargine at bedtime with sliding scale Humalog. # Hypotension: When transferred to the floor after his neuro ICU stay, pt was having asymptomatic episodes of hypotension. These resolved with adjusting antihypertensives - his home losartan was stopped, metoprolol was decreased to 6.125mg BID, and florinef was stopped. No evidence of infection. CHRONIC ISSUES ============== # Coronary Artery Disease s/p drug eluting stent: Continued home ASA, atorvastatin # Orthostatic Hypotension: Continued home fludrocortisone initially, but was subsequently discontinued given normotension. # Constipation: Pt was maintained on aggressive bowel regimen # Peptic ulcer disease: Continued home ranitidine 150 mg daily # Depression: # Autism spectrum d/o: Continued home Escitalopram Oxalate 20 mg PO DAILY; Continued home Divalproex (DELayed Release) 250 mg PO DAILY initially, but this dose was increased for seizure prophylaxis as above. Continued home QUEtiapine Fumarate 25 mg PO BID:PRN agitation. #HTN: Initially continued Losartan 25 mg daily, but this was stopped I/s/o hypotension. Decreased metoprolol tartrate to 6.125 BID. TRANSITIONAL ISSUES =================== [ ] Continue Depakote at current dose, no need to target specific level [ ] Please continue to monitor for signs of aspiration [ ] FYI foley is difficult to place, needs Urology to place given known urethral strictures. ___ the future, if the patient requires catheter placement, begin with a ___ coude catheter. There was minimal resistance with this sized catheter. [ ] As above, pt had multiple episodes of asymptomatic hypotension. Blood pressure control should be addressed on an ongoing basis # CODE: Full, presumed # CONTACT: Name of health care proxy: ___ Relationship: Friend Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fludrocortisone Acetate 0.2 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Divalproex (DELayed Release) 250 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. QUEtiapine Fumarate 25 mg PO BID:PRN agitation 8. Ranitidine 150 mg PO DAILY 9. Escitalopram Oxalate 20 mg PO DAILY 10. Glargine 22 Units Breakfast Glargine 22 Units Bedtime Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. Gabapentin 100 mg PO TID RX gabapentin 100 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 4. Metoprolol Tartrate 6.125 mg PO BID RX metoprolol tartrate 25 mg 0.25 tablet(s) by mouth twice a day Disp #15 Tablet Refills:0 5. Divalproex (DELayed Release) 500 mg PO BID RX divalproex ___ mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 6. Glargine 22 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus] 100 unit/mL AS DIR 22 Units before BED; Disp #10 Vial Refills:0 7. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 8. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 9. Escitalopram Oxalate 20 mg PO DAILY RX escitalopram oxalate 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 10. Finasteride 5 mg PO DAILY RX finasteride 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 11. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a day Disp #30 Packet Refills:0 12. QUEtiapine Fumarate 25 mg PO BID:PRN agitation RX quetiapine 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 13. Ranitidine 150 mg PO DAILY RX ranitidine HCl 150 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 14. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #30 Capsule Refills:0 15. HELD- Fludrocortisone Acetate 0.2 mg PO DAILY This medication was held. Do not restart Fludrocortisone Acetate until your PCP restarts the medication if necessary 16.___ Lift DX: Osteomyelitis s/p amputation M86.8X7, 730.17 ___: 12 months 17.___ Sling DX: Osteomyelitis s/p amputation M86.8X7, 730.17 ___: 12 months Quant: 5 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Right lower extremity ischemia with nonhealing right foot ulceration secondary to peripheral arterial disease, seizure, urinary tract infection, hypotension Secondary Diagnoses: Diabetes, hypertension, aspergers syndrome, CAD, depression Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL? You needed a procedure done to your leg to restore blood flow to it. WHAT HAPPENED WHILE YOU WERE HERE? You had the procedures that you needed to allow for enough bloodflow to your leg. Our podiatry team cleaned out your foot wounds multiple times, and you were treated with antibiotics through your IV. You unfortunately had an episode of acute confusion and difficulty with your breathing, for which you needed to be intubated for a few days (a tube was put down your throat to help you breathe). You had an MRI done of your brain that showed an old stroke, but nothing new. We believe the reason for your confusion was a seizure. We increased your Depakote which you were taking for your mood to a dose which also prevents seizures. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? Please continue to take all of your medications as directed, and follow up with all of your doctors. Again, it was a pleasure taking care of you! Sincerely, Your ___ Team Followup Instructions: ___
19822698-DS-13	19,822,698	24,821,476	DS	13	2148-09-29 00:00:00	2148-10-02 12:54:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Codeine Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: EGD ___ and ___ History of Present Illness: ___ year old female with h/o SCC (esophagus, lung, piriform sinus) s/p resection/CyberKnife followed by chemo + XRT who presents with dyspnea. She reports that she has had dyspnea "on and off" for several years. She notices that it is worse when she is up and about--doing her hair or getting dressed. She doesn't do much more exertion than that. She has also had chronic orthopnea, always using several pillows to sleep on. She can't think of any other symptoms that accompany her dyspnea--no chest pain, no dizziness, no palpitations. She has never had fevers or cough. She has intermittent swelling of her leg also, but this is when she is standing on it for a long time. She says this specific episode started yesterday night, but it has already resolved now "because I am resting". In the ED, initial vitals 98.6 66 150/96 22 100%. She was given lasix IV without improvement in symptoms. Her labs were remarkable for: Hgb at baseline (___), normal electrolyte, creatinine at baseline 1.2, and BNP elevated at 8000 from baseline of 5000. She had a CXR which was nonspecific so then she had a CTA chest which was negative for a PE but did show significant emphysema and RLL GGO with septal thickening. Because of these imaging findings she was given a dose of levofloxacin IV in the ED and admitted to medicine. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Squamous cell carcinoma of the esophagus status post resection, T3, N1, M0, surgery performed in ___. 2. Squamous cell carcinoma of the lung status post numerous CyberKnife as well as a lobectomy performed in ___. 3. Hypertension. 4. Hyperlipidemia. 5. Glaucoma. 6. Arthritis. 7. Coronary artery disease. 8. Colonic polyps. 9. Peripheral vascular disease status post a below knee amputation in ___. 10. Osteoporosis. 11. Status post oophorectomy. 12. stage IV squamous cell carcinoma involving the pyriform sinus. Social History: ___ Family History: Brother - lung CA Son - died age ___ (? type of cancer) Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.6 66 150/96 22 100% GENERAL: NAD, awake and alert HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, dry mucus membranes NECK: nontender and supple, no JVD, asymmetric right and left posterior cervical chains but no definite LAD BACK: no spinal process tenderness, no CVA tenderness CARDIAC: IRRR, nl S1 S2, no MRG LUNG: rales in the right base, remainder of lungs clear, no wheezing ABDOMEN: +BS, soft, NT, ND EXT: L BKA, right no edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, gait not assessed (needs prosthetic leg) SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM Vitals: 98.0 128/86 93 18 98%RA Weight: 98.7lb GENERAL: NAD, awake and alert HEENT: MMM NECK: nontender and supple, no JVD CARDIAC: IRRR, nl S1 S2, no MRG LUNG: CTAB ABDOMEN: +BS, soft, NT, ND EXT: L BKA, right no edema PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ___ 11:55AM BLOOD WBC-4.2 RBC-3.35* Hgb-10.6* Hct-33.0* MCV-99* MCH-31.6 MCHC-32.1 RDW-13.3 Plt ___ ___ 11:55AM BLOOD Glucose-100 UreaN-16 Creat-1.2* Na-134 K-4.1 Cl-99 HCO3-27 AnGap-12 ___ 06:50AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.5* ___ 11:55AM BLOOD proBNP-8123* ___ 01:55PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:55PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 01:55PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 . MICRO: BLOOD CULTURES X 2 PENDING . IMAGING: ___ CTA CHEST: CT CHEST: The airways are patent to the subsegmental level. There is no mediastinal, hilar or axillary lymph node enlargement by CT size criteria. There is extensive atherosclerotic disease of the aorta, coronary arteries, as well as the origin of the great vessels. Aortic valve calcifictions are also noted. Moderate enlargement of the heart is unchanged. There are bilateral nonhemorrhagic pleural effusion, left greater than right, unchanged in size compared to ___. There is no pneumothorax. Postoperative changes of esophagectomy with pull through are noted. There has been interval progression of right lower lobe ground glass opacities and interlobular septal thickening, which may be due to recurrent aspiration or possible superimposed infection. A few lung nodules are again seen in the right lower lobe, which are all unchanged in size since ___. The dominant subpleural lesion measures 7.7 mm, compared to 7.3 mm on prior study. There is significant bullous and centrilobular emphysema. A left lower lobe malignancy treated with CyberKnife is grossly unchanged in size and appearance. The ___ lesion in the right upper lobe treated with CyberKnife is also grossly unchanged in size. CTA CHEST: The aorta and main thoracic vessels are well opacified. The aorta demonstrates normal caliber throughout the thorax without intramural hematoma or dissection. The pulmonary arteries are opacified to the segmental level. There is no filling defect to suggest pulmonary embolism. No arteriovenous malformation is seen. oSSEOUS STRUCTURES: No focal osseous lesion concerning for malignancy. Although this study is not designed for assessment of intra-abdominal structures, the liver demonstrates a lobular contour in the posterior right lobe with an adjacent area of possible hyperdensity, incompletely characterized on this study. This area was not found to be FDG avid on PET scan from ___. IMPRESSION: 1. No evidence of pulmonary embolus. 2. Interval progression of right lower lobe ground glass opacities and interlobular septal thickening likely due to recurrent aspiration but superimposed infection cannot be excluded. 3. Significant bullous and centrilobular emphysema. 4. Unchanged size of lung nodules seen in the right lower lobe. 5. Lobular contour of the posterior right lobe of the liver with an adjacent area of hyperdensity, incompletely characterized on this study. This area was not found to be FDG avid on PET scan from ___. Attention on follow-up study is recommended. 6. Chronic findings include: stable appearance of right upper lobe and left lower lobe malignant nodules status post CyberKnife treatment, neoesophagus, moderate cardiomegaly and small, left greater than right bilateral pleural effusions. . ___ VIDEO SWALLOW EVAL: FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. Intermittent penetration was noted without gross aspiration. For details, please refer to speech and swallow note in OMR. IMPRESSION: Intermittent penetration, no aspiration. . ___ BARIUM SWALLOW EVAL: IMPRESSION: A short segment stricture immediately proximal to the site of anastomosis prevents passage of a 13 mm barium tablet, but presents no obstruction to the flow of liquids. . ___ TRANSTHORACIC ECHO: This study was compared to the prior study of ___. LEFT ATRIUM: Mild ___. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. ___ to severe (3+) MR. ___ VALVE: Mildly thickened tricuspid valve leaflets. TVP. Normal tricuspid valve supporting structures. No TS. Mild to moderate [___] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: Small pericardial effusion. No echocardiographic signs of tamponade. GENERAL COMMENTS: Bilateral pleural effusions. Ascites. Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed (ejection fraction 30 percent) secondary to severe hypokinesis of the inferior septum, inferior free wall, posterior wall, and lateral wall. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened (a vegetation cannot be excluded). Tricuspid valve prolapse is present. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of ___, mitral and tricuspid regurgitation are significantly increased. Left ventricular ejection fraction is reduced. Pleural and pericardial effusions, as well as ascites are now seen. Discharge Labs: ___ 06:50AM BLOOD WBC-3.3* RBC-3.13* Hgb-10.1* Hct-30.9* MCV-99* MCH-32.2* MCHC-32.6 RDW-13.5 Plt ___ ___ 06:50AM BLOOD ___ PTT-30.2 ___ ___ 06:20AM BLOOD UreaN-15 Creat-1.2* Brief Hospital Course: ___ year old female with h/o multiple squamous cell cancers (lung, esophagus and sinuses) s/p resections and chemo/XRT who presented with chronic dyspnea and dysphagia. Found to have new systolic heart failure and esophageal stricture. # Acute on chronic systolic heart failure, EF 30%: Regional wall motion abnormalities suggest ischemic cause for her failure. Overall, she appeared well compensated for her heart failure clinically with only mild edema and dyspnea, still with normal oxygen saturation on room air. However, we did change her medication regimen to optimize her heart rate less than 70, blood pressure, and allow for diuretic use for dyspnea relief. Her discharge cardiac regimen is: aspirin 81 mg daily, metoprolol succinate 50 mg daily, lisinopril 40 mg daily, furosemide 10 mg every other day. She was also continued on atorvastatin 80 mg daily and ezetimibe. # Afib: ___ score is 2 but she was taking aspirin only. She did not know about her increased risk of stroke from afib. After discussion of the risks and benefits of anticoagulation, she would like to start. Her primary care doctor thinks she will have high barriers to INR draws, and so we started dabigatran instead. She is rate controlled currently with her metoprolol succinate 50 mg daily. # Dysphagia: She describes her symptoms as a sensation that food gets stuck in her throat at about the level of the clavicle. More problems with swallowing solid foods (needs to wash everything down with water). She had a h/o numerous squamous cell cancers (lung, esophagus, and sinuses) now all are felt to be in remission per the oncologists. She underwent a video swallow which showed no oropharyngeal aspiration. She had a barium swallow which showed a stricture at the anastomosis of her esophagus and her neo-esophagus. She underwent an EGD with biopsy of this site, the results of which are pending. Depending on the biopsy results, there are plans for either a dilation of the stricture (if biopsy is benign) or stent placement (if biopsy is malignant) to relieve her symptoms. # Previous lung cancer: She had a CTA chest which did not show any PE but did show extensive emphysema and changes from chronic aspiration in the right lung. Her previously treated lung cancer (with cyberknife) was stable. # Hyperlipidema: continued atorvastatin and ezetimibe # Glaucoma: continued ophthal gtts # GERD: continued omeprazole TRANSITIONAL ISSUES: - Follow up biopsy of esophageal stricture and re-arrange GI follow-up for either dilation of the stricture (if biopsy is benign) or stent placement (if biopsy is malignant) to relieve her symptoms. - Patient needs to have an appointment with her prosthetics specialist since her prosthetic leg does not fit perfectly now that she has lost so much weight. - Started pradaxa for afib. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Dorzolamide 2%/Timolol 0.5% Ophth. 2 DROP BOTH EYES BID 6. Lisinopril 40 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. bimatoprost 0.01 % ___ 9. ezetimibe 10 mg Oral daily 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Q-Tussin DM (dextromethorphan-guaifenesin) ___ mg/5 mL oral 10 ML Q4H 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Dorzolamide 2%/Timolol 0.5% Ophth. 2 DROP BOTH EYES BID 5. ezetimibe 10 mg Oral daily 6. Lisinopril 40 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Furosemide 10 mg PO EVERY OTHER DAY RX furosemide 20 mg 0.5 (One half) tablet(s) by mouth every other day Disp #30 Tablet Refills:0 9. bimatoprost 0.01 % ___ 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Q-Tussin DM (dextromethorphan-guaifenesin) ___ mg/5 mL oral 10 ML Q4H 12. Dabigatran Etexilate 150 mg PO BID RX dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 Discharge Disposition: Home With Service Facility: ___ ___: systolic heart failure emphysema esophageal cancer s/p resection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because of shortness of breath that had been coming and going for a very long time. You had investigations of your heart which showed that it is not pumping well with each beat. This is called heart failure and we needed to change some of your blood pressure medications to help protect the heart from further damage. You also had a CT scan of your lungs, which showed that you have severe emphysema. This is from smoking for so many years. Patients with emphysema have ongoing shortness of breath, especially while walking or doing exercises. You were also having trouble swallowing solid foods. You had a swallowing test performed and it showed a narrowing in the distal esophagus. You had 2 camera studies done with biopsies to look for another cancer in the esophagus. They will let you know what the biopsy results show at your follow-up appointments. You will probably need more treatments to open this area up further. It was a pleasure taking care of you in the hospital! Followup Instructions: ___
19823084-DS-8	19,823,084	20,044,393	DS	8	2143-05-08 00:00:00	2143-05-08 22:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: scalp laceration repair History of Present Illness: Ms ___ is a ___, ___, with h/o DM on metformin, CVA in ___, presents with syncope today. Patient was at doctor's office when she suddenly felt lightheaded, with nausea, diplopia, palpitations. She was attempting to sit down but seems that the floor was somewhat slippery and she miscalculated how far the seat was and fell back onto her left side. Patient reports transient loss of consciousness. She had no post-syncopal confusion but unclear how long LOC. She had trauma to posterior scalp but no other injuries. Her husband witnessed the fall and denies seizure activity, and no loss of bowel or bladder continence. The patient reports that for the past six months she has orhtostatic symptoms. As of ___ she has been wearing an event monitor (scheduled for one month) for w/u of dizziness, but denies any previous syncopal episodes. She does report h/o exertional shortness of breath of unclear duration. No exertional chest pain, orthopnea. ? mild leg swelling. Patient was taken to the ED where initial VS were 98.0 86 176/86 18 99% on RA. She was found to have a scalp lac on her occiput and 7 staples were placed. TDAP was given. Labs showed: negative U/A, lactate 1.3, trop < 0.01, lytes, CBC, and LFTs all normal. CT C-spine and CT Head were negative for acute fracture or bleed. CXR showed no pulm congestion or consolidation. EKG showed NSR, no signs of ischemia. VS prior to transfer were 99.0 ___ 100% on RA. Upon arrival to the floor, the patient has no complaints. She denies dizziness, chest pain, palpitations, shortness of breath, headache or blurry vision. Past Medical History: - headaches since ___ - cholelithiasis - CVA - ___ (residual left arm and leg paresthesias?) - DM - started on metformin 3 mo ago for a1c of 7.5, no glucometer - HTN Social History: ___ Family History: Denies h/o sudden cardiac death. Physical Exam: ADMISSION VS - 98.4 110/58 82 /18 /100ra GENERAL - well-appearing obese woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, nl S1-S2, ___ LSB systolic murmur ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - left scalp laceration, no active bleeding LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout . DISCHARGE 98.8 118/60 84 18 95RA GENERAL - well-appearing obese woman in NAD HEENT - MMM, NECK - no JVD LUNGS - CTA bilat HEART - RRR, nl S1-S2, ___ LSB systolic murmur ABDOMEN - NABS, soft/NT/ND EXTREMITIES - WWP, no c/c/e SKIN - left scalp laceration, no active bleeding or drainage NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout Pertinent Results: ADMISSION ___ 04:00PM BLOOD WBC-6.6 RBC-4.32 Hgb-12.9 Hct-39.3 MCV-91 MCH-29.8 MCHC-32.7 RDW-13.4 Plt ___ ___ 04:00PM BLOOD Neuts-63.4 ___ Monos-3.5 Eos-0.8 Baso-0.9 ___ 04:00PM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-141 K-3.9 Cl-104 HCO3-29 AnGap-12 ___ 04:00PM BLOOD Albumin-4.8 Calcium-10.0 Phos-4.0 Mg-2.2 . PERTINENT ___ 04:00PM BLOOD cTropnT-<0.01 ___ 12:44AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 12:44AM BLOOD CK(CPK)-60 ___ 04:00PM BLOOD Lipase-32 ___ 04:09PM BLOOD Lactate-1.3 ___ 04:00PM BLOOD ALT-24 AST-22 AlkPhos-51 TotBili-0.5 ___ 4:20 pm BLOOD CULTURE Pending . DISCHARGE ___ 08:10AM BLOOD WBC-6.6 RBC-4.33 Hgb-13.0 Hct-40.4 MCV-93 MCH-30.0 MCHC-32.2 RDW-13.5 Plt ___ ___ 08:10AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-141 K-4.5 Cl-104 HCO3-27 AnGap-15 ___ 08:10AM BLOOD Calcium-9.8 Phos-3.6 Mg-2.3 . CT C-SPINE ___ 2:20 ___ FINDINGS: There is no acute fracture or malalignment. The prevertebral soft tissues are normal. There are mild degenerative changes at T1-2 with anterior osteophyte formation. No other significant degenerative changes are present. There is no spinal canal or neural foraminal narrowing. The apices of the lungs are clear. The thyroid is unremarkable. There is no lymphadenopathy. The visualized portion of the brain is unremarkable. IMPRESSION: 1. No acute fracture or malalignment. 2. Mild degenerative changes in the upper thoracic spine. . HEAD CT ___ 2:20 ___ FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are normal in size for the patient's age. The basal cisterns are patent. Periconfluent periventricular white matter hypodensities are most consistent with chronic small vessel ischemic disease. Hypodensity in the right putamen may be prior lacunar infarct vs perivascular space. The gray-white matter differentiation is preserved. There is a moderate left parietal scalp hematoma. No fracture is identified. There is mild mucosal thickening within the left maxillary sinus. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: 1. No acute intracranial process. 2. Left parietal scalp hematoma without associated fracture. 3. Chronic small vessel ischemic disease. . CXR ___ 2:36 ___ FINDINGS: Single portable view of the chest. No prior. Low lung volumes seen on the current exam. There is no large confluent consolidation. The upper mediastinal contour appears prominent, potentially in part due to tortuous vessels and low lung volumes and portable technique. Cardiac silhouette is however normal given technique. Surgical clips seen in the right upper quadrant. There is no visualized fracture. IMPRESSION: Prominent upper mediastinal caliber, potentially due to tortuous vessels, portable supine technique. PA and lateral may offer additional detail when patient is amenable. x x x x x x x x x x x x x xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx ___ MEDICAL RECORDS: Note from neurology ___ (Dr ___, Dr ___ ___: Dizziness: related to neck pain/osteoarthritis not likely cerebellar or neuro process CVA: ? paroxysmal atrial fibrillation as underlying cause of stroke-ordered event monitor and recommended work up OSA MRA ___ for w/u dizziness 1. Old infarctions of bilateral frontotemporal centrum semiovale and tiny chronic small lacunar infarcts in the bilateral basal ganglia. 2. Mild cerebral volume loss with chronic white matter small vessel ischemic change without acute infarction, hemorrhage or abnormal enhancement. 3. Atrophic change due to old infarction or congenital hypoplasia of the posterior body of the corpus callosum. 4. Focal moderate stenosis involving the mid M2 segment of the left MCA with preseved flow in distal branches. Remaining arteries of ant and post intracranial circulation are patent w/o aneurysm or stenosis. 5. normal mra of neck w/ contrast (no vertibrobasilar disease) . ___ Dipyrimadole stress test for ___ chest pain: no evidence of ischemic EKG changes . ECHOCARDIOGRAM ___ EF 60% LV wall motion normal; normal LV thickness ___ dilated trace MR, NORMAL MV trace TR, normal TV AV normal PV normal aortic root normal pulm art nomal . Brief Hospital Course: Ms ___ is a ___ ___ speaking woman with h/o DM, HTN, CVA ___ who presents with syncopal episode preceded by lightheadedness, nausea, palpitations. . # Syncope History suggestive of vasovagal syncope given preceding prodrome of nausea, palpitations and blurry vision. History of orthostatic symptoms and previous h/o stroke concerning for possible vertebrobasilar insufficency or peripheral neuropathy with autonomic dysfunction from DM. However, review of OSH records revealed recent MRA with normal posterior ciruculation. No concern for seizure given no previous h/o seizure and no suggestive findings per witness. Cardiac symptoms also concerning for potential cardiac cause such as valvular disease or arrhythmia. Her cardiac enzymes were negative and EKG was reassuring. Review of recent OSH echocardiogram revealed normal valvular function. The patient had no events on telemetry during her inpatient stay. However, the patient is currently being evaluated with 30 day event monitoring for work-up of paroxysmal atrial fibrillation. Review of medications revealed that daily injections of "cerebrolysin" (see below) could potentially contribute to her symptoms. She was instructed to stop using this until further evaluation. (While metformin does not typically cause hypoglycemia and patient's BG was normal to elevated during her course, she does not monitor BG with relationship to symptoms.) The patient improved symptomatically overnight. Her orthostatic vital signs were within normal limits and she was feeling well prior to discharge. The patient was instructed to folow up with her PCP for further evaluation upon discharge. . # Diabetes Mellitus. The patient reports recent diagnosis of DM with A1C of 7.5. Her metformin was held in the inpatient setting and she was treated with sliding scale insulin. She was discharged on her previous dose of metformin. She should follow up with her PCP for further monitoring. She should be encouraged to check her BG with symptoms of hypoglycemia. . # HTN Hypertensive in ED to 176/86 but normalized upon arrival to the floor. She remained normotensive for the remainder of her course and was discharged on her home regimen of lisinopril and amlodipine. . # HLP She was discharged on her home dose Simvastatin 40mg daily. Her CK was WNL. This should be re-evaluated in the outpatient setting and potentially reduced to Simvastatin 20mg given risk of rhabdomyalysis with concomittent use of Amlodipine. . # h/o CVA No intracranial hemorrhage noted on CT. Neuro exam stable throughout her course. She was continued on Aspirin 81mg daily. Of note, the patient reported that she was using an injectable medication for stroke prevention. While the exact details including drug name and dosage could not be confirmed, the description was consistent with drug called "cerebrolysin." As this drug has the potential to cause dizziness, flushing and palpitations, it may contribute to some of the symptoms the patient is describing. Relationship of symptoms to timing of use unclear but it appears that she uses daily injection for 30 days ___. She was asked to discontinue use until further investigation by her PCP or neurologist. . # SCALP LACERATION Patient incurred 3 cm laceration as a result of her fall. This was repaired in the ED. She was instructed to follow up with her PCP for removal of staples in one week. Medications on Admission: Metformin 500mg daily Lisinopril 2.5mg daily Simvastatin 40mg daily amlodipine 10mg dialy alprazolam 0.25mg BID prn anxiety tylenol prn Raphacholin- dosage unknown ? Cerebrolysin (complex dosing schedule, daily injections for 30 days ___ Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain. 2. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. simvastatin 20 mg Tablet Sig: Two (2) Tablet PO once a day. 4. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day: with meal. 5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: syncope, scalp laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You were admitted to the hospital because you had a fall and injured your scalp. While you were here, we did some tests that showed you had no bleeding in your brain, and you got staples put in to close the cut in your scalp. We also monitored your heart and found no abnormalities while you were here. Please continue wearing the heart monitor and follow up with your primary care physician within one week of discharge for further evaluation and for removal of the staples in your scalp. We obtained records from your previous doctors which ___ ___ that your heart and blood flow to your brain were not likely causing your dizziness. When you follow up with your primary care doctor and your neurologist, it is very important to tell them that you are taking "cerebrolysin," as this could be responsible for some of your symptoms. For now, we would recommend that you stop taking this until further discussion with your doctors. You should also be careful when using the medication, alprazolam, as it can also cause dizziness and increase your chances of falling. You should also discuss this medication with your doctor. MEDICATION CHANGES: STOP cerebrolysin It was a pleasure taking care of you. Followup Instructions: ___
19823084-DS-9	19,823,084	28,711,627	DS	9	2144-06-09 00:00:00	2144-06-15 16:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Reason for Consultation: left sided symptoms Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Our patient is a ___ ___ speaking woman who presents with one day of decreased sensation in her left arm and left leg. She is interviewed with the assistance of a ___ interpreter. She has a reported history of prior ischemic stroke in ___ which resulted in left arm and left leg numbness, weakness, and clumsiness, and she has vascular risk factors including hypertension, diabetes, and obstructive sleep apnea (not on CPAP). She recovered from those symptoms over a course of 5 months. She takes clopidogrel and reports adherence to her medications. She has some baseline left-sided weakness but noticed that at 11 AM yesterday while leaving a store her arm and leg became "harder to control." She describes the sensory change as diminishment and "numbness." Some small movements of her hands became more difficult. These symptoms did not involve her face or right side. These persisted to today and have not improved or worsened per her report. She denies any other symptoms and feels that the symptoms are less severe than they were with her prior stroke; these are otherwise the exact same symptoms in the absence of headache and dizziness which she also had the time of the prior reported stroke. She has otherwise been well recently and denies any antecedent illness or infectious symptoms. Two weeks ago she had a dull, frontal and vertex, non-throbbing headache for a few days that went away in the absence of any other symptoms. In ___, she had fallen and hit her ___ but had no subsequent consequences of that injury. It is not clear if she has a Neurologist but she has received some neurologic testing in the ___ system. She reports that in recent months she had an electromyogram and nerve conduction study which revealed some degree of neuropathy in her right arm and right leg. This was performed because she was complaining of some pain in those limbs. She claimed she had an MRI here in ___, but it turns out that this was a CT scan last ___. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies muscle weakness. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: PMH/PSH: [] Neurologic - Ischemic stroke (reported, in ___ in ___, left hemiparesis, hemisensory disturbance, headache, dizziness; resolved symptoms, no recurrence since per patient), occasional Headaches [] Cardiac - ? Atrial fibrillation (in Cardiology documentation, reported by patient but never confirmed), HTN [] Endocrine - DM2 (on Metformin, no glucometer at home) [] Pulmonary - OSA (not on CPAP) Social History: ___ Family History: Family History: No known history of neurologic disease including ischemic stroke or intracranial hemorrhage. Physical Exam: Exam on admission: Physical Examination: VS T: 97.8 HR: "25" in the listed vital signs but approximately 66 on my exam BP: 119/46 RR: 17 SaO2: 94% RA General: NAD, lying in bed comfortably, well-appearing middle-aged woman. / ___: NC/AT, no conjunctival icterus, no oropharyngeal lesions / Neck: Supple, no nuchal rigidity, no meningismus, no carotid/subclavian/vertebral bruits / Cardiovascular: RRR, no M/R/G / Pulmonary: Equal air entry bilaterally, no crackles or wheezes / Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses / Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Attention to examiner easily attained and maintained. Recalls a coherent history. Structure of speech demonstrates fluency with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No dysarthria. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch and pin bilaterally. [VII] Left nasolabial fold flattening. Mildly decreased movement of the left lower face. Symmetric forced eyelid closure. [VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [XII] Tongue midline. - Motor - Normal bulk and tone. Left hand pronation, no drift. No tremor or asterixis. [ Direct Confrontational Strength Testing ] Arm Deltoids [C5] [R 5] [L 4+] Biceps [C5] [R 5] [L 5] Triceps [C6/7] [R 5] [L 4] Extensor Carpi Radialis [C6] [R 5] [L 5-] Extensor Digitorum [C7] [R 5] [L 4+] Flexor Digitorum [C8] [R 5] [L 5] Interosseus [C8] [R 5] [L 4+] Abductor Digiti Minimi [C8] [R 5] [L 4+] Leg Iliopsoas [L1/2] [R 5] [L 4+] Quadriceps [L3/4] [R 5] [L 5] Hamstrings [L5/S1] [R 5] [L 4] Tibialis Anterior [L4] [R 5] [L 4] Gastrocnemius [S1] [R 5] [L 5] Extensor Hallucis Longus [L5] [R 5] [L 4+] Extensor Digitorum Brevis [L5] [R 5] [L 4+] - Sensory - No deficits to pin or proprioception bilaterally, but she describes ___ diminishment of light touch sensation on the left arm and left leg. - Reflexes =[Bic] [Tri] [___] [Quad] [Gastroc] L 2 2 2 2 1 R 2 2 2 2 1 Plantar response flexor on right, extensor on the left. - Coordination - Left hand dysmetria with finger to nose testing bilaterally, right intact. Good speed and intact cadence with rapid alternating movements on the right, slow on the left. - Gait - Normal initiation. Narrow base. Normal stride length and arm swing. Stable without sway. Slight sway with Romberg. Pertinent Results: ___ 02:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD ___ 02:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-3 TRANS EPI-<1 ___ 11:45AM GLUCOSE-189* UREA N-21* CREAT-0.6 SODIUM-144 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-18 ___ 11:45AM ALT(SGPT)-19 AST(SGOT)-19 ALK PHOS-53 TOT BILI-0.3 ___ 11:45AM ALBUMIN-5.0 CALCIUM-10.1 PHOSPHATE-2.8 MAGNESIUM-2.0 ___ 11:45AM WBC-3.8* RBC-4.60 HGB-13.6 HCT-41.2 MCV-90 MCH-29.6 MCHC-33.1 RDW-13.2 ___ 11:45AM NEUTS-56.3 ___ MONOS-7.1 EOS-1.1 BASOS-0.9 ___ 11:45AM PLT COUNT-235 ___ 11:45AM ___ PTT-29.1 ___ WBC 3.8, Hgb 13.6, Plt 235, MCV 90, PTT 29.1, INR 1 Na 144, K 4, Cl 104, HCO3 26, BUN 21, Cr 0.6, Glu 189 (triage 236), Ca ___, Mg 2, Phos 2.8 AST 19, ALT 19, AP 53, T.bili 0.3, Alb 5 UA negative ECG VR 75 bpm, no clear ischemic changes EKG ___: Sinus rhythm. Borderline left axis deviation. Left ventricular hypertrophy by voltage in lead aVL. Compared to the previous tracing of ___ axis is slightly more leftward. R wave is more prominent in lead aVL. Read ___. IntervalsAxes ___ ___ CT ___ ___: FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or acute large vascular territorial infarction. Prominent ventricles and sulci likely reflect age related atrophy. Basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is identified. The paranasal sinuses, mastoid air cells, middle ear cavities are clear. Globes are unremarkable. IMPRESSION: No acute intracranial abnormality. CXR PA/lat ___: FINDINGS: The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac silhouette is top normal. The mediastinal and hilar contours are unremarkable. Mild thoracolumbar scoliosis is noted. IMPRESSION: No acute cardiopulmonary process. TTE ___: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.4 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Stroke Volume: 137 ml/beat Left Ventricle - Cardiac Output: 7.82 L/min Left Ventricle - Cardiac Index: 4.09 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.08 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 8 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Arch: 2.8 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 33 Aortic Valve - LVOT diam: 2.3 cm Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Mitral Valve - E Wave deceleration time: 186 ms 140-250 ms TR Gradient (+ RA = PASP): 16 to 24 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR. ___ VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is elongated. A patent foramen ovale is present. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No significant valvular abnormality. Early appearance of agitated saline bubbles in the left atrium/ventricle with the patient coughing or performing the Valsalva maneuver. This finding is most consistent with a patent foramen ovale B/l LENIs ___: FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep vein thrombosis in bilateral lower extremity veins. MR ___ w/o contrast and MRA ___ ___: MR ___: Ventricles and sulci are mildly enlarged, reflecting parenchymal volume loss. There is no intracranial hemorrhage. Note is made of periventricular and deep white matter FLAIR signal hyperintensities, indicative of chronic microvascular disease. Note is made of abnormally slow diffusion involving the right periventricular white matter, extending inferiorly towards the posterior aspect of the the right external capsule. Encephalomalacia noted in the right paramedian frontal lobe, in keeping with prior vascular insult. MR ANGIOGRAM NECK: As noted above, time-of-flight MR angiography is obtained, without intravenous contrast. The patient declined contrast injection and chose to abort the examination. Images acquired of the cervical vertebral, common carotid and internal carotid arteries show no luminal caliber irregularities to suggest pseudoaneurysm, dissection or thromboembolic filling defect. However, note should be made that the origins of these vessels are not distinctly visualized. MR ANGIOGRAM ___: Primary intracranial arterial structures demonstrate appropriate signal intensity. There are no luminal caliber irregularities to suggest aneurysm, dissection or occlusive thromboembolic filling defect. Anatomy is conventional in orientation. IMPRESSION: 1. New curvilinear right infarction, appearing to involve areas of right periventricular white matter, extend inferiorly towards the right external capsule. 2. No intracranial hemorrhage. 3. Normal MR angiography of the ___ and neck. Please note that the patient refused intravenous contrast and further imaging and as such the origins of the vertebral and common carotid arteries are not visualized. Brief Hospital Course: ___ ___ woman who presented with left-sided weakness and sensory disturbances similar to prior symptoms of a reported stroke in ___. Her symptoms of stroke in ___ included a left hemiparesis and sensory loss from which she recovered over five months; she has a residual left hemiparesis, reported previously. She has diabetes, hypertension, and obstructive sleep apnea. Her symptoms suddenly worsened 1 day PTA at 11 AM in the absence of any apparent trigger. Her symptoms have persisted without any improvement. Her examination was notable for left nasolabial fold flattening, left-handed pronation, left arm and left leg mild hemiparesis, and minimal diminishment of light touch sensation in the left arm and left leg (poorly localizing) with normal pin and proprioception, left hand dysmetria, and left extensor plantar response. These findings have now resolved. Her noncontrast ___ CT is similar to a scan one year prior, except perhaps a small hypodensity in the right pons and midbrain which may be an artifact. This clinical history was suspicious for reexpression of symptoms from a prior neurologic injury (namely her prior reported stroke) or a possible new injury from ischemic stroke or another cause elsewhere along the corticospinal-sensory-coordination pathways. Pt was therefore admitted to the neurology service for a stroke workup. She reports a prior clinical diagnosis of atrial fibrillation without any documented evidence, including a negative ___ of Heart outpatient monitoring recently. Her cardiologist is unaware of any evidence that she has ever had atrial fibrillation. MRI of the brain did show a new right-sided subcortical infarct. The following stroke risk factors were evaluated: - MRA vessel imaging did not demonstrate any obvious occlusions. - Telemetry monitoring showed no evidence of atrial fibrillation or another abnormal rhythm - Echocardiogram with bubble study showed a PFO with normal cardiac function. B/l LENIs did not show a DVT - Fasting lipid panel (TChol 132, HDL 33, LDL 77, ___ 109) at goal. No change in lipid medications during this admission. Diet and exercise education was provided, as this may help with raising pt's HDL. - A1C was 5.8 (nondiabetic) - BP was under good control during this admission. At this point, no etiology of pt's stroke has been determined; however, her stroke appears embolic, and occasional paroxysmal atrial fibrillation remains the strongest possibility. This was discussed with pt's outpt cardiologist, who may pursue further atrial fibrillation workup. To prevent further strokes, anticoagulation with warfarin was offered despite any firm evidence of atrial fibrillation. However, pt refused this due to the complexity of monitoring. Instead, it was decided to change pt's clopidogrel to ASA as pt has had an ischemic events on the former. Her other medications for HTN and hyperlipidemia will be continued. Pt will f/u in neurology stroke clinic with Dr. ___, and in cardiology clinic with Dr. ___. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 77) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No (no documented atrial fibrillation, and pt refused warfarin)- () N/A Medications on Admission: Medications: Clopidogrel 75 mg daily, amlodipine 10 mg daily, fenofibrate 54 mg daily, lisinopril 2.5 g daily, metformin 500 mg twice daily, simvastatin 40 mg daily, Colace 100 mg twice daily Discharge Medications: 1. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:5 2. fenofibrate NF* 54 mg Oral daily 3. Amlodipine 10 mg PO DAILY 4. Gabapentin 300 mg PO BID 5. Lisinopril 2.5 mg PO DAILY 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Docusate Sodium 100 mg PO BID:PRN constipation 8. Simvastatin 40 mg PO DAILY 9. Outpatient Physical Therapy Discharge Disposition: Home Discharge Diagnosis: Ischemic Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the stroke service after you had sudden onset of weakness on your left side. Although most of your symptoms resolved within hours of your presentation there was evidence of an ischemic stroke on your MRI. An ischemic stroke is a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. We did not see evidence of atrial fibrillation on your telemetry or on ECGs. We discussed this with your cardiologist, Dr. ___ asked that you be seen in his clinic next week for possible longer-term monitoring. You were taking only Plavix on admission and there was some concern that you were not responding to this medication. We opted to switch you to aspirin at 325 mg daily. Although we discussed coumadin therapy, there was no clear evidence of atrial fibrillation and you were reluctant to start this medication given the complexity of monitoring. The risks were explained to you that you may be at risk for another stroke without coumadin, but you declined. You will need to stop your Plavix (clopidegrel) You will need to take aspirin (325 mg every day) You will follow up with both Dr. ___ in cardiology and Dr. ___ in neurology. All these discussion were had with the ___ interpreter over the phone and you told us that you understood. Followup Instructions: ___
19823136-DS-16	19,823,136	20,688,923	DS	16	2110-02-28 00:00:00	2110-03-03 10:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: iodine / Penicillins / cefdinir / shellfish derived / codeine Attending: ___ Chief Complaint: Whooshing sound in ears Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old lady with recent diagnosis of atrial fibrillation, recent hospitalization for bilateral ischemic infarcts (L parietal and right occipital) with residual left homonymous hemianopia who presents as transfer from ___ after having sudden onset "whooshing sound", increased floater and visual aura in left visual field. History obtained from her and her son at the bedside. Unfortunately the records from ___ are not available to me at this time. Per the patient, her troubles began when she has a superficial lower leg skin infection in early-mid ___ for which she took doxycycline. She then developed a UTI and was on some antibiotic for this. Then she was scheduled to see her doctor ___ couple of weeks ago and while she was at the doctors office, she suddenly loss vision in her left visual field. She then went to ___ who reportedly did NHCHCT with showed small L parietal hemorrhage. She was transferred to ___ for further management. MRI there actually showed right occipital infarct and left parietal infarct with small hemorrhagic conversion. She was also noted to be in atrial fibrillation. Her stroke was attributed to atrial fibrillation. They started aspirin and the plan was for repeat ___ and then initiation of Eliquis as an outpatient given small left hemorrhagic conversion. Her hospital course was complicated by pneumonia. She also was having left visual field auras consisting of flashes of color, rain, images of face and cars. She had an EEG which reportedly showed no seizures. She was discharged to rehab ___. She did well at rehab and was discharged home on ___ of this week. She has been doing well at home with ongoing left visual field loss with intermittent auras. Her blood pressures have been well controlled. She has had chronic left and bifrontal headaches without associated nausea/vomiting or photophobia. On the morning of presentation she developed a whooshing sounds on the left side of her head. She had no change in the character of her chronic headache. She had no nausea or vomiting. She also noted increased visual auras in her left visual field (images of rain, faces, cars). Due to this she went to ___. She was neurologically normal with only known left visual field cut. ___ showed 5.7 x 2.7 x 4.5 hemorrhagic transformation of prior known right occipital infarct with partial effacement of right ventricle. Given this, she was transferred to ___ for further care. On arrival to ___, she is well appearing and able to relay interval history and story quite well. She is currently having her daily headache without increase in intensity or associated n/v. She has no new numbness/tingling, weakness, visual symptoms other than ones above, problems with speech. She denies fevers, chills, cough, SOB, abdominal pain, dysuria, diarrhea. ROS: Positive per HPI, otherwise negative. Past Medical History: PMH: hypertension recent diagnosis of atrial fibrillation but only on aspirin due to hemorrhagic conversion recent PNA during hospitalization for stroke recent UTI recent cellulitis cataract surgery Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ====================== Vitals: T98.8 64 20 121/80 MAP: 93.7 100 General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk post surgical. EOMI without nystagmus. Left homonymous hemianopia V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF. -Gait: did not walk given on nicardipine gtt DISCHARGE PHYSICAL EXAM: ====================== Vitals: Temp: 98.5 PO BP: 147/85 HR: 59 RR: 18 O2 sat: 98% O2 delivery: Ra Intermittent positive visual phenomena in L visual hemifield. General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to exam. Language is fluent, Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: PERRL 3 to 2mm and brisk bilaterally. EOMI without nystagmus. Left homonymous hemianopia. Facial sensation intact to light touch. No facial droop, facial musculature symmetric. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis, noted. Full strength throughout. -Sensory: No deficits to gross touch b/l. Pertinent Results: ___ 11:04PM BLOOD WBC-21.8* RBC-3.59* Hgb-9.1* Hct-29.8* MCV-83 MCH-25.3* MCHC-30.5* RDW-14.6 RDWSD-43.6 Plt ___ ___ 07:45AM BLOOD WBC-28.0* RBC-3.98 Hgb-10.0* Hct-32.9* MCV-83 MCH-25.1* MCHC-30.4* RDW-14.7 RDWSD-43.7 Plt ___ ___ 11:04PM BLOOD Neuts-63.5 Lymphs-13.8* Monos-19.8* Eos-1.5 Baso-0.6 Im ___ AbsNeut-13.83* AbsLymp-3.00 AbsMono-4.32* AbsEos-0.33 AbsBaso-0.13* ___ 04:10PM BLOOD Neuts-66.3 Lymphs-12.2* Monos-18.4* Eos-1.5 Baso-0.7 Im ___ AbsNeut-13.09* AbsLymp-2.41 AbsMono-3.63* AbsEos-0.29 AbsBaso-0.14* ___ 04:21AM BLOOD Neuts-62.8 Lymphs-13.7* Monos-20.5* Eos-1.6 Baso-0.6 Im ___ AbsNeut-12.99* AbsLymp-2.83 AbsMono-4.23* AbsEos-0.34 AbsBaso-0.12* ___ 11:04PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-1+* Polychr-NORMAL ___ 11:04PM BLOOD ___ PTT-27.6 ___ ___ 04:23AM BLOOD ___ ___ 11:04PM BLOOD Glucose-86 UreaN-8 Creat-0.9 Na-139 K-3.9 Cl-104 HCO3-23 AnGap-12 ___ 07:45AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-140 K-4.1 Cl-103 HCO3-21* AnGap-16 ___ 11:04PM BLOOD ALT-21 AST-23 CK(CPK)-54 AlkPhos-75 TotBili-0.6 ___ 11:04PM BLOOD Lipase-46 ___ 11:04PM BLOOD CK-MB-1 ___ 11:04PM BLOOD cTropnT-<0.01 ___ 11:04PM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.4 Mg-2.0 ___ 07:45AM BLOOD %HbA1c-5.4 eAG-108 ___ 04:21AM BLOOD Triglyc-148 HDL-29* CHOL/HD-4.3 LDLcalc-67 ___ 11:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:06PM BLOOD Lactate-1.3 ___ 03:22AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 03:22AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Imaging: ___ MRI brain w/wo: 1. Right PCA territory hemorrhagic infarction. 2. There is mild edema surrounding the lesion causing mass effect and effacement of the occipital horn of the right lateral ventricle. 3. Small focus of subarachnoid hemorrhage at the vertex of the left parietal lobe. ___ CT chest w: 1. No convincing evidence of intrathoracic malignancy. 2. Small nodule in the lower outer right breast is noted for which mammographic correlation is recommended. 3. Small left pleural effusion. 4. 4 mm left upper lobe pulmonary nodule may represent an incidental finding. Attention on follow-up imaging is recommended. 5. Penetrating atherosclerotic ulcer in the aorta in the distal aortic arch. 6. Please see separately submitted report of CT Abdomen and Pelvis from the same date for description of subdiaphragmatic findings. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. ___ CT abd/pelvis w: 1. Soft tissue mass interposed between the left gluteus maximus and medius muscles, of uncertain etiology, possibly a nerve sheath tumor. Nonemergent pelvic MRI with without contrast is recommended for further evaluation. 2. Please see the separately submitted report of the same day CT Chest for findings above the diaphragm. RECOMMENDATION(S): Nonemergent pelvic MRI with without contrast is recommended. Brief Hospital Course: Ms. ___ is a ___ year old female with recent diagnosis of atrial fibrillation on aspirin, recent who was admitted after presentation for whooshing sound and increasing left visual field positive visual phenomena found to have right occipital hemorrhage likely due to hemorrhagic transformation. BPs were well-controlled during her hospital stay, initially with nicardipine gtt in the ICU, then with her home antihypertensives once she was transferred to the floor. MRI head was done and negative for evidence of CAA but did show small area of left SAH at the vertex of the left parietal lobe. LDL was 67, HgbA1C 5.4. Aspirin was initially held but restarted on ___. Her deficits improved prior to discharge and the only notable persistent exam finding was left homonymous hemianopsia, and continuing intermittent L hemifield positive visual phenomena. These positive visual phenomena were unclear seizure vs cortical spreading depression. Extended routine EEG was performed, and preliminary read shows no epileptiform activity, final read pending. Suspect cortical spreading depression as etiology of these phenomena. No antiepileptic medications were started. MRI brain w/wo contrast did show significant contrast enhancement of the R occipital infarct, which raised concern for underlying lesion, though this could be fully explained by enhancement of subacute infarction. She had CT torso which showed 4mm lung nodule, no f/u needed given low risk patient; 4mm R breast nodule, for which radiology recommended mammogram. However, Ms. ___ has had mammogram in the last several months and knows that there is a breast lesion that has been followed over time and is not felt to be concerning for malignancy. It is possible that this lesion on CT is the same lesion. Also on CT torso, a soft tissue mass between the left gluteus medius and maximus was found, felt likely nerve sheath tumor on imaging. Ms. ___ states that this lesion is known and has previously been biopsied, so no further inpatient workup was pursued. Course also complicated by leukocytosis to ___, with no fever and no infectious s/s. This was discussed with hematology, who noted that this has previously been worked up. Ms. ___ follows with a hematologist as outpatient, and no workup was pursued as inpatient. Her stroke risk factors include the following: 1. Atrial fibrillation 2. Hypertension 3. Previous smoking ======================== AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (bleeding risk, hemorrhage, etc.) 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. ALPRAZolam 0.25 mg PO BID:PRN anxiety 3. Aspirin 81 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Ferrous GLUCONATE 324 mg PO BID 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Furosemide 20 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Losartan Potassium 25 mg PO DAILY 11. Metoprolol Tartrate 50 mg PO BID 12. Nystatin Ointment 1 Appl TP BID 13. Omeprazole 20 mg PO DAILY 14. Penlac (ciclopirox) 8 % topical daily 15. Saccharomyces boulardii 250 mg oral BID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. ALPRAZolam 0.25 mg PO BID:PRN anxiety 3. Aspirin 81 mg PO DAILY 4. Ferrous GLUCONATE 324 mg PO BID 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Fluticasone Propionate NASAL 1 SPRY NU BID 7. Furosemide 20 mg PO DAILY 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Losartan Potassium 25 mg PO DAILY 10. Metoprolol Tartrate 50 mg PO BID 11. Nystatin Ointment 1 Appl TP BID 12. Omeprazole 20 mg PO DAILY 13. Penlac (ciclopirox) 8 % topical daily 14. Saccharomyces boulardii 250 mg oral BID 15. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hemorrhagic transformation of acute ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of hearing a "whooshing sound" and increased floaters and visual aura in left visual field resulting from HEMORHAGIC TRANSFORMATION of an acute ischemic stroke, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. Hemorrhagic transformation is a common problem after a stroke from lack of blood. It means that there was some bleeding into the area recently injured from lack of blood. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. EEG - You had an EEG, a brain wave test, to see if there was any indication of some of your vision changes being from seizure. The preliminary result of that test was normal. We ___ call you if the final result (which ___ become available ___ is anything other than normal. We were also slightly worried because the area of stroke around the area of bleeding picked up more contrast dye than we expected, so, to be extra thorough, we looked for cancer. We saw no signs of cancer in your body. We did see the small growth between some of the muscles in your right buttock, but you told us that this is known and has been biopsied in the past, so there is nothing more that needs to be done about this. There was also a tiny area of possible concern in your right breast, and the radiologists thought it would be important for you to get a mammogram, but you have had one recently and know of a spot in your breast that has been followed over time and is not thought to be concerning. We ___ send these records to your primary care physician so she can compare this spot to the area on the mammogram and make sure they are the same spot. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: 1. Atrial fibrillation 2. Hypertension 3. Previous smoking We are changing your medications as follows: - No changes at this time. - After MRI to be obtained in approx. 1.5 weeks (2 weeks after you came in), talk to your Neurologist. If you do not have any increased bleeding on that scan, your neurologist might switch you from aspirin to a stronger blood thinner, apixaban. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
19823854-DS-9	19,823,854	24,408,560	DS	9	2111-08-10 00:00:00	2111-08-10 17:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an otherwise healthy ___ M w/ h/o viral pericarditis in ___, now presenting for eval of approximately 4d h/o flulike symptoms, now associated with chest pain pressure and intermittent palpitations. He began experiencing fevers, chills and mild pharyngitis on ___ evening. Last night, he developed R-sided upper back pain with radiation into bilateral arms as well as chest, most prominently in the retrosternal region but also diffusely across the precordial area. Chest pain has fluctuated between ___ severity, is non-pleuritic and dull, less improved with position than prior but pt states that sx are reminiscent with that of ___ episode. Pt reports that pain was initially improved with head pads but less so this morning. He has been taking muscle relaxants with no relief, as well as ibuprofen around the clock with the last dose at midday and 5x 81mg tablets of ASA PTA this morning. Patient has not had flu shot this season, denies recent sick contacts, food exposures, travel outside of country, outdoor activities and tick exposures. He denies associated SOB, n/v, dysuria, diarrhea, rash. Past Medical History: 1. CARDIAC RISK FACTORS: N/A 2. CARDIAC HISTORY - h/o viral pericarditis in ___, tx at ___, per pt had negative stress test as outpatient follow-up 3. OTHER PAST MEDICAL HISTORY Per pt, h/o - Hypercholesterolemia - Degenerative disk disease - R facial paresthesia Social History: ___ Family History: - Father h/o stroke at ___, long-standing smoker and h/o multiple MIs - Mother h/o Type II DM - Twin sisters h/o ___ syndrome, one sister h/o breast cancer at age ___ Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VITALS: 97.9 PO 126/90 HR 105 RR 18 97% RA GENERAL: Sitting up comfortably, NAD, speaking in full sentences. HEENT: PERRLA, EOMI, oropharynx benign NECK: supple, no lymphadenopathy CARDIAC: Slightly tachycardic but regular rhythm, normal S1, S2. No murmurs/rubs/gallops. Chest pain non-reproducible. LUNGS: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No c/c/e. BACK: no cva tenderness, no spinal or paraspinal tenderness. R upper back pain non-reproducible. NEURO: CN II-XII grossly intact, strength 5+/5 in UE and ___ bilaterally. DISCHARGE PHYSICAL EXAMINATION: =============================== VITALS: 97.6 PO 114/76L HR 95 RR 18 97 GENERAL: Sitting up comfortably, NAD, speaking in full sentences. HEENT: PERRLA, EOMI, oropharynx benign NECK: supple, no lymphadenopathy CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. Chest pain non-reproducible. LUNGS: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No c/c/e. BACK: no cva tenderness, no spinal or paraspinal tenderness. R upper back pain non-reproducible. NEURO: grossly intact, no deficits Pertinent Results: =================== LABS ON ADMISSION =================== ___ 11:00PM CK(CPK)-435* ___ 11:00PM CK-MB-17* MB INDX-3.9 cTropnT-0.38* ___ 05:29PM LACTATE-1.3 ___ 05:25PM CK(CPK)-513* ___ 05:25PM cTropnT-0.31* ___ 05:25PM CK-MB-27* MB INDX-5.3 ___ 01:50PM URINE HOURS-RANDOM ___ 01:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 01:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:50PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 01:50PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 11:00AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 10:55AM GLUCOSE-103* UREA N-11 CREAT-0.9 SODIUM-142 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-23 ANION GAP-19* ___ 10:55AM estGFR-Using this ___ 10:55AM ALT(SGPT)-19 AST(SGOT)-49* CK(CPK)-502* ALK PHOS-65 TOT BILI-0.4 ___ 10:55AM LIPASE-15 ___ 10:55AM cTropnT-0.29* ___ 10:55AM CK-MB-33* MB INDX-6.6* ___ 10:55AM ALBUMIN-4.5 ___ 10:55AM WBC-13.2* RBC-4.69 HGB-14.4 HCT-42.8 MCV-91 MCH-30.7 MCHC-33.6 RDW-13.7 RDWSD-45.5 ___ 10:55AM NEUTS-78.3* LYMPHS-11.0* MONOS-9.4 EOS-0.5* BASOS-0.3 IM ___ AbsNeut-10.35* AbsLymp-1.46 AbsMono-1.25* AbsEos-0.06 AbsBaso-0.04 ___ 10:55AM PLT COUNT-238 =================== LABS ON DISCHARGE =================== ___ 06:50AM BLOOD WBC-13.6* RBC-4.27* Hgb-12.7* Hct-39.4* MCV-92 MCH-29.7 MCHC-32.2 RDW-13.4 RDWSD-45.4 Plt ___ ___ 06:50AM BLOOD Plt ___ ___ 06:50AM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-144 K-3.9 Cl-103 HCO3-25 AnGap-16 ___ 06:50AM BLOOD CK(CPK)-283 ___ 06:50AM BLOOD CK-MB-9 cTropnT-0.31* ___ 06:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1 ==================== PERTINENT IMAGING: ==================== ___ CXR IMPRESSION: No acute intrathoracic process. ___ CTA Chest IMPRESSION: No evidence of pulmonary embolism or aortic abnormality. Bronchial wall thickening and hazy nodular opacities suggestive of bronchitis/small airways disease. Brief Hospital Course: Mr. ___ is an otherwise healthy ___ M w/ h/o viral pericarditis in ___, now p/w 4d h/o flulike symptoms, now associated with chest and back pain. Constellation of sx reminiscent with previous episode and labs notable for elevated cardiac markers, leukocytosis and EKG showing diffuse ST elevations in multiple leads and PR depression in lead II. ACUTE ISSUES #chest and back pain #fever, chills #myopericarditis Pt presented with fevers, chills a/w back and chest pain reminiscent of prior episode of viral pericarditis in ___. He was afebrile with improvement in pain with ibuprofen given in ED. Labs notable for positive trop x4 0.29 -> 0.31 -> 0.38 -> 0.31 ___s CK: 502 -> 513 -> 435 -> 283 MB: 33 -> 27 -> 17 -> ___ MBI: 6.6 -> 5.3. EKG notable for diffuse ST elevations in multiple leads and pr depression in lead II, together supporting dx of myopericarditis with likely viral etiology. Patient is now without chest pain and Trop has downtrended. Echo will be deferred to outpatient to evaluate possible myocarditis given his well-appearing clinical status. Continue Ibuprofen 800 mg PO TID and Colchicine 0.6 mg PO BID. Pt was given one dose of metoprolol tartrate 6.25 mg but was not continued. Urine cultures were negative. =========================== Transitional issues ========================== [] follow up urine culture [] order outpatient echo to evaluate for myocarditis [] Reevaluate colchicine and ibuprofen regimen for treatment completion for pericarditis and determine appropriate duration based on clinical symptoms Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. DULoxetine 30 mg PO DAILY Discharge Medications: 1. Colchicine 0.6 mg PO BID RX colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Ibuprofen 800 mg PO Q8H take for at least 2 weeks and then follow up with your primary doctor. RX ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp #45 Tablet Refills:0 3. DULoxetine 30 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Myopericarditis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ ___ was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== You were having chest pain and found to have inflammation on the lining of your heart. WHAT HAPPENED IN THE HOSPITAL? ============================== You were treated with medications to reduce the inflammation in your heart. WHAT SHOULD I DO WHEN I GO HOME? ================================ Please continue to take all of your medications as directed, and follow up with your primary care doctor. You need to talk to your primary care doctor about scheduling an echocardiogram to look for inflammation in the heart. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
19823926-DS-8	19,823,926	21,124,355	DS	8	2120-04-06 00:00:00	2120-04-08 16:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: right hand sensory changes Major Surgical or Invasive Procedure: na History of Present Illness: The pt is a ___ year-old R-handed female with hx of left opthalmic artery/ICA aneurysm with s/p coiling who presents with right hand sensory changes. She was at her baseline until yesterday during the day when she was eating a meal when her right arm became numb from the elbow down to the hand. She states it initially was the entire hand that was numb. Sensation slowly came back but she was left with parasthesias of pins and needles feeling of the medial wrist and 3 fingers. This sensory change has persisted since then. She has not had any weakness or clumbsiness of that hand. She has been able to text and use objects with the hand despite the sensory changes. No overuse recently or trauma. Nothing has made it better. She cannot think of anything that provoked or makes it worse. She ultimatley presented to ___ where they did an MRI brain, on the scan they noted several hyperintense lesions but no concern for acute stroke. She called her neurosurgeon here about these findings, because he was unable to see the imaging suggested she come into the ED for further evaluation. On neuro ROS, she has an intermittent headache which is no worse than her typical headache lately, otherwise denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Opthalmic artery aneurysm coiling ___, found due to headaches/dizziness Cholecystectomy Social History: ___ Family History: no family history of autoimmune diseases, MS, strokes Physical Exam: Physical Exam: Vitals: Temp98.6 HR83 BP126/93 RR14 Sat100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple. No nuchal rigidity Pulmonary: normal work of breathing, non-labored CV: RRR, well perfused throughout Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. Subjective sensory changes in ulnar distribution of right arm below the elbow, not changed during sensory testing but with testing she had no deficits in that area. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Pertinent Results: ___ 01:20PM GLUCOSE-101* UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15 ___ 01:20PM PLT COUNT-230 ___ 01:20PM ___ PTT-30.1 ___ ___ 01:20PM NEUTS-67.1 ___ MONOS-5.7 EOS-1.0 BASOS-0.8 ___ 01:20PM WBC-4.7 RBC-4.33 HGB-13.9 HCT-42.2 MCV-98 MCH-32.0 MCHC-32.8 RDW-12.8 ___ 05:50AM BLOOD ESR-2 ___ 11:06AM BLOOD ANCA-NEGATIVE B ___ 11:06AM BLOOD ___ dsDNA-NEGATIVE ___ 05:50AM BLOOD RheuFac-5 CRP-0.5 ___ 03:00PM BLOOD ANGIOTENSIN 1 - CONVERTING ___ MRA with contrast: 1. Enhancing foci within left frontal and temporal lobe in association with marked T2 signal abnormality seen on most recent outside facility MRI -- overall findings concerning for inflammatory process such as acute disseminating encephalomyelitis (ADEM), or vasculitis as described above. 2. Unchanged appearance of coiled left supraclinoid internal carotid artery aneurysm with minimal residual filling. LP WBC 0; RBC 0; polys 0; lymphs 96; monos 4; prot 21; glucose 68 ___ 02:16PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA (PCR)-Negative ___ 02:16PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA, QUALITATIVE, PCR-Negative ___ 02:16PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-Negative ___ 02:16PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Negative ___ 02:16PM CEREBROSPINAL FLUID (CSF) ___ VIRUS, QUAL TO QUANT, PCR-Negative ___ 02:16PM CEREBROSPINAL FLUID (CSF) ___ VIRUS, QUAL TO QUANT, PCR-Ngative ___ 02:16PM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS (MS) PROFILE-15 oligoclonal bands; high IgG index. Brief Hospital Course: Ms ___ is a ___ year-old R-handed woman with PMH significant for recent opthalmic artery/ICA aneurysm s/p coiling (at the end of ___ who presented with right hand sensory changes. Her MRI shows multiple White Matter FLAIR lesions (without diffusion changes) only in the right hemisphere. They were not present in the MRI done about 3 days after the aneurysm coiling, but appears in the MRI done in the beginning of ___. This MRI from the beginning ___ also showed some enhancement of one of the FLAIR lesions (white matter underlying posterior insula). She had recently an outpatient MRI which showed more ___ lesions. Repeat MRI done during her hospitalization showed that more of these lesions showed an enhancement while the original posterior peninsular lesion showed less enhancement compared to the ___ MRI. LP shows: WBC: 0 RBC: 0 protein: 21 Glu: 68. However, more detailed testing shows that she has 15 oligoclonal bands as well as a high CSF IgG index. Very unclear what the etiology of these lesions are. They appear to be inflammatory but not infectious based on the CSF profile. The CSF pattern would be consistent with an MS or ADEM pattern, however, her protein is normal. CSF pattern could also be any other immunological reaction than MS. ___ pattern of lesions are not characteristic for MS and the successive appearance of new lesions would make it less likely to be ADEM. She also does not have any clinical history of typical MS symptoms ___ intermittent visual problems, no double vision, no unsteadiness and no episodes of incontinence). It is of interest that all of the lesion are on the side of the coil which raises the question of whether or not she has a reaction to the coil or the contrast used during its placement - though this would be a very uncommon reaction. The patient was treated with IV solumedrol 1 G daily for 5 days followed by a PO prednisode taper. She was given GI ppx while on steroids. She will follow up in the neurology clinic and will have another MRI after her next follow-up visit. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO HS insomnia/anxiety Discharge Medications: 1. Lorazepam 0.5 mg PO HS insomnia/anxiety 2. MethylPREDNISolone Sodium Succ 1000 mg IV Q24H 3 doses total as an out patient. ___ RX methylprednisolone sodium succ 1,000 mg 1 bag IV daily Disp #3 Vial Refills:0 3. Ranitidine 150 mg PO BID take as long as you are on steroids RX ranitidine HCl [Acid Reducer (ranitidine)] 150 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 4. PredniSONE 20 mg PO DAILY Duration: 9 Days taper as follows starting ___: 40mg x3; 20mg x3; 10mg x1; 10mg x1; 10mg x1 Tapered dose - DOWN RX prednisone 20 mg 2 tablet(s) by mouth daily Disp #11 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: right sided paresthesias Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear MS ___, You were hospitalized due to symptoms of right sided sensory changes and an abnormal MRI. We performed a spinal tap which did not shown any abnormalities on the preliminary testing. We have a number of studies which are still pending at this time. We have started you on a steroid which we hope will decrease the inflammation seen on your MRI scan. Please follow up at the ___ hospital tomorrow at 11am for your IV steroids. You will have 3 more days total of the IV steroids followed by a quick taper of steroids by mouth. The steroid taper will be as follows: 40mg for 3 days followed by 20mg for 3 days followed by 10mg for 3 days and then discontinue steroids. Followup Instructions: ___
19824245-DS-15	19,824,245	23,241,495	DS	15	2178-05-25 00:00:00	2178-05-26 12:05:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: latex Attending: ___. Chief Complaint: severe nausea Major Surgical or Invasive Procedure: none History of Present Illness: ___ s/p laparotomy and bilateral ovarian cystectomies for likely bilateral endometriomas on ___. EBL from case 300cc. Immediate postoperative course complicated by postop ileus that ultimately resolved. As of ___, the patient was tolerating small amounts of PO, nausea resolved and was passing gas. She was discharged to home ___. Patient reported going home and eating a peanut butter sandwich. She had no issues with the sandwich and went to sleep. She had not yet filled her Rx. Woke up around ___ with severe nausea. Came to ED for evaluation and management. She reports burping but not passing any gas. She reports feeling like she has to pass gas. Mild incisional pain with walking. Denies lightheadedness, dizziness, chest pain, shortness of breath. Has not had any emesis since discharge. ROS: negative except for pertinent positives and negatives above. Past Medical History: - ? Endometriosis - Low grade lymphoma, at least stage IIIs, last seen ___ with recommendation for expectant observation, plan for 3 month follow-up with her oncologist Dr. ___. Social History: ___ Family History: -Denies a known family history of breast, ovarian, uterine, cervical, or colon malignancy Physical Exam: CV: RRR Lungs: CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, incision/dressing clean/dry/intact GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally Pertinent Results: ___ 06:41AM BLOOD WBC-5.7 RBC-3.81* Hgb-10.0* Hct-31.7* MCV-83 MCH-26.2 MCHC-31.5* RDW-14.5 RDWSD-44.1 Plt ___ ___ 05:58AM BLOOD WBC-5.3 RBC-3.34* Hgb-8.9* Hct-27.8* MCV-83 MCH-26.6 MCHC-32.0 RDW-14.4 RDWSD-44.3 Plt ___ ___ 06:50AM BLOOD WBC-5.1 RBC-3.44* Hgb-9.0* Hct-28.5* MCV-83 MCH-26.2 MCHC-31.6* RDW-14.5 RDWSD-43.4 Plt ___ ___ 05:50AM BLOOD WBC-4.9 RBC-3.13* Hgb-8.1* Hct-25.6* MCV-82 MCH-25.9* MCHC-31.6* RDW-14.6 RDWSD-43.0 Plt ___ ___ 05:45AM BLOOD WBC-7.8 RBC-3.81* Hgb-10.1* Hct-31.3* MCV-82 MCH-26.5 MCHC-32.3 RDW-14.8 RDWSD-44.4 Plt ___ ___ 05:50AM BLOOD WBC-5.7 RBC-3.28* Hgb-8.8* Hct-26.7* MCV-81* MCH-26.8 MCHC-33.0 RDW-14.6 RDWSD-43.2 Plt ___ ___ 05:45AM BLOOD Neuts-78.9* Lymphs-9.3* Monos-8.4 Eos-1.3 Baso-0.4 Im ___ AbsNeut-6.13* AbsLymp-0.72* AbsMono-0.65 AbsEos-0.10 AbsBaso-0.03 ___ 06:41AM BLOOD Glucose-89 UreaN-3* Creat-0.5 Na-140 K-4.1 Cl-100 HCO3-28 AnGap-12 ___ 05:58AM BLOOD Glucose-87 UreaN-4* Creat-0.5 Na-139 K-3.9 Cl-99 HCO3-24 AnGap-16 ___ 06:50AM BLOOD Glucose-91 UreaN-6 Creat-0.5 Na-138 K-4.1 Cl-98 HCO3-25 AnGap-15 ___ 05:50AM BLOOD Glucose-90 UreaN-7 Creat-0.5 Na-138 K-3.7 Cl-100 HCO3-25 AnGap-13 ___ 05:45AM BLOOD Glucose-124* UreaN-9 Creat-0.5 Na-139 K-4.1 Cl-99 HCO3-22 AnGap-18 ___ 05:50AM BLOOD Glucose-113* UreaN-6 Creat-0.5 Na-137 K-3.9 Cl-100 HCO3-25 AnGap-12 ___ 06:41AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.9 ___ 05:58AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.9 ___ 06:50AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 ___ 05:50AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8 ___ 05:45AM BLOOD Albumin-4.2 Calcium-9.5 Phos-4.5 Mg-1.9 ___ 05:50AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.8 Brief Hospital Course: Ms. ___ was admitted to the gyn/onc service with nausea/vomiting on ___ for suspected ileus after being discharged from the hospital on the previous day. Patient was made NPO. Her abdominal exam showed no peritoneal signs during her stay and she remained afebrile with a normal white blood cell count. An abdominal xray (supine and upright) demonstrated multiple dilated loops of small bowel and air-fluid levels, with air still seen in the colon. Per radiology, in the setting of recent intervention, findings likely represent ileus. For this, patient was managed conservatively. On hospital day 2, diet was advanced to clears and crackers, but patient had an episode of emesis and so was switched to bowel rest and IV fluids. was passing flatus and subsequently had a bowel movement. On hospital day 3, patient was passing more flatus and her diet was slowly advanced to clear. She tolerated crackers and clears on hospital day 4. She continued to pass flatus with bowel movements and had a normal abdominal exam. That day, patient noted some serosanguinous drainage from her incision site. This was evaluated and approximately 5cc of serosanguinous fluid was expressed. There was no evidence of infection at the time. On hospital day #5, she was advanced to a regular diet, which she tolerated well. She was thus discharged home in stable condition on hospital day #5. Regarding the serosanguinous drainage, patient was instructed to follow up on her post operative visit and to call if she noticed any symptoms of purulent discharge, erythema, fevers or pain at the incision site. Medications on Admission: Medications: - Gummy vitamins - Liquid Tylenol, ibuprofen, oxycodone, Ativan for postop Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Duration: 24 Hours RX acetaminophen 500 mg/15 mL 15 mL by mouth every 6 hours Disp #1 Bottle Refills:1 2. Enoxaparin Sodium 40 mg SC Q24H RX enoxaparin 40 mg/0.4 mL 40 mg SC every day Disp #20 Syringe Refills:0 3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every 6 hours Disp #50 Tablet Refills:1 4. LORazepam 0.5 mg IV Q4H:PRN anxiety/nausea RX lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth every 4 hours Disp #30 Tablet Refills:0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #15 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ileus Bilateral ovarian endometriomas and pelvic endometriosis. Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecologic oncology service for treatment of ileus after your operative procedure. You have recovered well and the team feels that you are safe to be discharged home. Please follow these instructions: Post operative instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for ___. * No heavy lifting of objects >10 lbs for 4 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Abdominal instructions: * Take your medications as prescribed. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over your incision; no scrubbing of incision. No bath tubs for 6 weeks. * Leave your steri-strips on. If they are still on after ___ days from surgery, you may remove them. * You have a small area of serosanguinous drainage in the middle of your wound. At this time, it does not appear to be infected. Please continue to cover that area with gauze and dressing and follow up at your post operative visit. Please call the gynecology ___ clinic if you experience fevers, chills or note redness around the incision. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. *Lovenox injections* - Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. - You will be discharged with a daily Lovenox (blood thinning) medication. - This is a preventive dose of medication to decrease your risk of a forming a blood clot. - You will need to continue taking these lovenox injections for a total of 28 days following surgery. A visiting nurse ___ assist you in administering these injections. Followup Instructions: ___
19824245-DS-22	19,824,245	21,154,145	DS	22	2178-08-24 00:00:00	2178-08-24 17:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ yo woman with high grade B cell lymphoma on DA-EPOCH-R who presents with 1 day of low back pain. She reports she was in her USOH until yesterday morning when she sneezed, fell to her knees, and "threw out" back. No head strike or LOC. Says pain has been ___ since, took ibuprofen and iced back w/ no improvement. Says pain is diffuse over lower back. Describes pain as constant and worsened with movement. Denies neurological deficits in legs, no saddle anesthesia, no urinary/bowel incontinence. Also has had runny nose since ___ w/ associated dry cough intermittently. No SOB or sputum production. Had temp of 100 this morning. Of note, Ms ___ was admitted ___ for scheduled chemotherapy. On presentation, she reported severe lower back pain for which her chemo was held for 2 days while she underwent MRI for workup. MRI of cervical and thoracic spine showed diffusely decreased marrow signal without focal lesions and the etiology of her pain remained elusive. During her hospitalization, her back pain varied in location (mostly over the left lower back) and was so severe as to cause her to be notably tearful, restless, and hyperventilating. In the ED: 98.2 F \| 126 \| 122/74 \| 20 \| 100% RA. Her pain was assessed to most likely be musculoskeletal. She refused rapid flu swab. Her initial workup was remarkable for worsening pancytopenia (ANC 300-> 60; hgb 7.2-> 6.1; plt 82-> 56) compared to yesterday. In the ED she was given: ___ 12:31 IV HYDROmorphone (Dilaudid) .5 mg ___ ___ 13:18 PO Acetaminophen 650 mg ___ ___ 13:18 IV Ondansetron 4 mg ___ ___ 13:18 IVF LR ___ Started ___ 14:35 IVF LR 1000 mL ___ Stopped (1h ___ ___ 14:35 IV LORazepam 1 mg ___ ___ 16:10 mouth NYSTATIN NF ___ 23:03 IV Acetaminophen IV 1000 mg ___ 01:14 PO/NG Acyclovir 400 mg ___ 07:28 IV Acetaminophen IV 1000 mg Upon arrival to the floor, she affirms the above history and notes that she has had a small bump on her arm for the past week, and it is painful to touch. === REVIEW OF SYSTEMS === Constitutional: No fevers, chills, night sweats. Appetite is okay. No fatigue Neurologic: No headache, blurry vision, numbness or tingling, focal weakness HEENT: No rhinorrhea, sore throat, nonproductive cough Cardiovascular: No chest pain, palpitations Respiratory: No shortness of breath, Gastrointestinal: No abdominal pain, nausea/vomiting, diarrhea, constipation. Genitourinary: No dysuria, hematuria Hematologic: No easy bruising or bleeding Musculoskeletal: No myalgias, swelling Dermatologic: No rashes. small bump left arm All other review of systems are negative unless stated otherwise Past Medical History: -Endometriosis -High grade B cell lymphoma -Bilateral Ovarian Cystectomies s/p laparotomy c/b ileus ___ ONCOLOGIC HISTORY: - ___: pelvic MRI showed splenomegaly and enlarged lymph nodes involving the mesentery, retropecotral and periportal space. Chest CT showed bilateral axillary lymphadenopathy, no significant mediastinal lymphadenopathy, and confirmed splenomegaly 13.6 cm, and multiple enlarged gastrohepatic and ___ lymph nodes. - ___: ultrasound guided right axillary lymph node needle core biopsy which showed follicular lymphoma, low grade. The immunostaining showed the B cells positive for CD20, CD10, BCL-2, and BCL-6. ___ showed a proliferative index of 15%. - ___: recommendation for expectant management with a 3 month follow-up CT for low grade lymphoma was made; she did not keep her appointments. - ___: ___ with nausea. CT showed: 1. interval increase in size and number of numerous enlarged mesenteric, retroperitoneal, and ___ lymph nodes in addition to interval enlargement of the spleen is concerning for lymphoproliferative disorder. 2. Complex multiloculated cystic right adnexal lesion measuring 19 x 13 x 15 cm mildly increased in size from prior study (15 x 12 x 14 cm). Interval enlargement and extrinsic compression of the sigmoid colon against the sacrum are likely contributing to the patient's increasing constipation and abdominal distension. - ___: initial visit to Gyn Onc for eval of adnexal mass. Plan for laparascopic surgical evaluation. Reported difficulty with eating, bloating, unintentional 10 lb weight gain. She denies n.v, pelvic pain, abnormal bleeding, vaginal discharge, or change in her bladder habits. - ___: pt rescheduled surgery to ___ - ___: ED for abdominal pain, resolved without intervention. - ___: admission for ex lap - ___: Exploratory laparotomy, bilateral ovarian cystectomies performed. Diagnosis: Bilateral ovarian endometriomas and pelvic endometriosis. Biopsies sent. C/b post-op ileus. - ___: Hem/pathology of ovary tissue: HIGH GRADE B-CELL LYMPHOMA; SEE NOTE. By immunohistochemistry, the abnormal lymphoid cells are positive for CD20 and CD10 and BCL6 and are negative for MUM1. CD3 and CD5 highlight a small population of admixed T cells. BCL2 diffusely stains both B-cells and T-cells. CD21, CD23 and BCL1 are negative. By Ki-67 immunostaining, the proliferation index approaches 100%. In-situ hybridization for ___ virus encoded RNA ___ ISH) is negative. Epithelial membrane stain is negative. Taken together, the findings are in keeping with involvement by a high grade B cell lymphoma with a germinal center(GC) phenotype. The morphologic features are those of a diffuse large B cell lymphoma - ___: Cytogenetics: FISH: POSITIVE for IGH/BCL2, IGH/MYC and GAIN of BCL6. C/w Double Hit Lymphoma - ___: admission for n/v. Likely ileus, treated conservatively with resolution. - ___: Initial outpatient evaluation by Dr. ___, NP. Recommendation for admission to begin da-EPOCH-R that day, but ___ refuses admission. - ___: Staging PET reveals extensive FDG avid left supraclavicular, bilateral axillary, mesenteric, portocaval, retroperitoneal, and left inguinal adenopathy, as well as low right pelvis FDG avidity possibly indicative of bowel involvement by lymphoma, and multiple foci of FDG avidity in the bones, including the right iliac bone and the sternum. - ___: Baseline TTE reveals an LVEF of 50-55%. - ___: C1 da-EPOCH - ___: Dose 1 Rituxan - ___: IT MTX - ___: admission for C1 post LP headache and CSF leak - ___: 2 day h/o RUE swelling/erythema. Venous u/s shows right basilic vein thrombosis involving the insertion site of a previously inserted PICC line. Lovenox and keflex initiated. - ___: admit for C2 da-EPOCH - ___ IT MTX - ___ admit for C3 da-EPOCH dose level 3 - ___ admit for C4 da-EPOCH Social History: ___ Family History: -Denies a known family history of breast, ovarian, uterine, cervical, or colon malignancy Physical Exam: ADMISSION PHYSICAL EXAM ======================== VITALS: ___ 0854 Temp: 99.4 PO BP: 113/78 HR: 121 RR: 18 O2 sat: 97% O2 delivery: Ra General: Tearful and slightly hyperventilationg, but calms down when interviewed Neuro: Cranial nerves: PERRL, EOMI, Facial sensation equal bilaterally, resists eye opening ___, hearing intact to finger rub b/l, palate elevates symmetrically, tongue midline, shoulder shrug ___ Motor: ___ deltoid, bicep, tricep, handgrip bilaterally ___ hip flexion, knee extension/flexion, plantar and dorsiflexion on right ___ hip flexion on left Pain in back with passive internal rotation of right hip. No pain with movement of left hip, knee, ankle Sensation intact to light touch over UE and ___ Alert and oriented to person, place, and situation HEENT: alopecia, normocephalic, small white plaques on tongue Cardiovascular: tachycardic, regular rhythm, no m/r/g Chest/Pulmonary: Lungs clear to auscultation. no wheezes, rhonchi, or crackles Abdomen:Soft, nontender. Well healed surgical scar. No hepatosplenomegally Extr/MSK: Strength as above in neuro exam. small mobile tender nodule in right upper extremity in distal triceps Skin: Pale, warm, well perfused. NO rashes. Back: No ecchymosis, redness, or swelling. Nontender to palpation throughout her spin DISCHARGE PHYSICAL EXAM ======================== 24 HR Data (last updated ___ @ 550) Temp: 98.2 (Tm 98.8), BP: 106/72 (102-110/68-75), HR: 90 (90-114), RR: 18 (___), O2 sat: 99% (96-99), O2 delivery: Ra, Wt: 130.8 lb/59.33 kg General: young adult woman appearing uncomfortable, though in NAD Neuro: AAOx3, face symmetric, moves all four w purpose. HEENT: alopecia, normocephalic, small white plaques on tongue Cardiovascular: tachycardic, regular rhythm, no m/r/g Chest/Pulmonary: CTAB. no wheezes, rhonchi, or crackles Abdomen: Soft, nondistended nontender. Well healed surgical scar. Extr/MSK: Small mobile mildly tender nodule in right upper extremity in distal triceps. BACK: Low back no TTP over spinous processes or paraspinous muscles. Mildly increased muscle tension. Skin: Pale, warm, well perfused. NO rashes. Pertinent Results: ADMISSION LABS ================ ___ 12:28PM BLOOD WBC-0.4* RBC-2.23* Hgb-6.1* Hct-18.3* MCV-82 MCH-27.4 MCHC-33.3 RDW-16.7* RDWSD-50.6* Plt Ct-56* ___ 12:28PM BLOOD Neuts-16* Lymphs-65* Monos-12 Eos-3 Baso-4* AbsNeut-0.06* AbsLymp-0.26* AbsMono-0.05* AbsEos-0.01* AbsBaso-0.02 ___ 12:28PM BLOOD Glucose-108* UreaN-5* Creat-0.5 Na-140 K-3.9 Cl-102 HCO3-23 AnGap-15 DISCHARGE LABS =============== ___ 06:25AM BLOOD WBC-33.3* RBC-2.91* Hgb-7.9* Hct-25.5* MCV-88 MCH-27.1 MCHC-31.0* RDW-17.5* RDWSD-54.8* Plt ___ ___ 06:25AM BLOOD Neuts-43 Bands-20* Lymphs-5* Monos-8 Eos-0* ___ Metas-7* Myelos-16* NRBC-0.4* AbsNeut-20.98* AbsLymp-1.67 AbsMono-2.66* AbsEos-0.00* AbsBaso-0.33* ___ 06:25AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-145 K-4.0 Cl-102 HCO3-27 AnGap-16 ___ 08:20AM BLOOD ALT-55* AST-28 AlkPhos-78 TotBili-0.3 ___ 06:25AM BLOOD Calcium-9.4 Phos-5.7* Mg-1.9 IMAGING/STUDIES ================ ___ RUE ULTRASOUND 2 adjacent primarily hypoechoic complex subcutaneous nodules in the posterior right upper arm, with peripheral vascularity, the largest measuring up to 1.3 cm. In the setting of recent injections, these most likely represent small abscesses. Correlate clinically for signs of inflammation/infection at this site. ___ RUE DOPPLER IMPRESSION: 1. No evidence of deep vein thrombosis in the right upper extremity. 2. Previously seen superficial thrombus in the right basilic vein is not seen on the current study. MICRO ======== __________________________________________________________ ___ 8:20 am BLOOD CULTURE X 1. Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 5:20 pm BLOOD CULTURE Source: Venipuncture X 1. Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 10:10 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: PATIENT SUMMARY ============================ ___ yo woman with high grade B cell lymphoma on DA-EPOCH-R who presented with 1 day of low back pain. === ACUTE ISSUES === # Low back pain During last hospitalization, complained of severe low back pain. MRI was unrevealing. This admission, pain likely caused by marrow expansion with GSF and MSK in the setting of fall onto knees and strain from sneezing, and exam also reveals exacerbation withinternal rotation of right hip. Physical therapy was consulted and they recommended home with walker for unsteady gait. She was treated with lidocaine patch, cyclobenzaprine, acetaminphen, and loratadine. She was DC with loratadine and lidocaine patches. # Low grade fever # Neutropenia # Nodules right upper extremity Patient likely with viral URI iso sore throat, cough, but refused swab in ED. She was initially neutropenic, but counts have recovered with GSF. Only localizing symptom was bump she noted in right upper extremity where she injected Lovenox. Ultrasound ___ with possible abscesses right upper extremity, though much more likely small hematoma from injection and exam benign. Nodule is nontender and without surrounding erythema or warmth. # Thrush Had been on nystatin at home. Not on formulary due to nationwide shortage, so was continued on Clotrimazole 1 TROC PO QID while inpatient. #High grade lymphoma, on da-EPOCH-R (last received C4D1 ___, D12 on admission ___ Extensive FDG avid left supraclavicular, bilateral axillary, mesenteric, portocaval, retroperitoneal, and left inguinal adenopathy as well as low right pelvis FDG avidity possibly indicative of bowel involvement by lymphoma, and multiple foci of FDG avidity in the bones, including the right iliac bone and the sternum. She was continued on acyclovir and bactrim ppx, as well as Ativan PRN, Zofran PRN, Compazine PRN. # Tachycardia Was also tachycardic last admission, likely due to pain, although possible infection as above. Also may have component of anxiety. Improved with IVF. # Hx of PICC associated DVT (___). Resolved on ultrasound ___. Enoxaparin was stopped on DC due to resolution of DVT. # Pancytopenia # Neutropenia # Anemia In s/o chemotherapy, recovering during this admission. Daily neupogen was discontinued this admission. TRANSITIONAL ISSUES =================== []F/u with Dr. ___ []Started loratadine for low back pain []Provided pt with walker to assist with ambulation []Consider need for outpatient ___ []Trialed cyclobenzaprine without benefit []STOPPED Enoxaparin as UE DVT resolved Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Enoxaparin Sodium 60 mg SC Q12H 3. Lidocaine 5% Patch 1 PTCH TD QPM 4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN headache 5. Vitamin D 800 UNIT PO DAILY 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Gummies Children Multivitamin (pediatric multivitamin no.30) 1 tablet oral DAILY 8. Filgrastim-sndz 300 mcg SC Q24H 9. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth discomfort 10. Loratadine 10 mg PO DAILY PRN allergies 11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 12. LORazepam 0.5-1 mg PO Q4H:PRN nausea anxiety insomnia 13. ___ ___ UNIT PO Q6H Discharge Medications: 1. Loratadine 10 mg PO DAILY BACK PAIN RX loratadine [Allergy Relief (loratadine)] 10 mg 1 tablet(s) by mouth daily Disp #3 Tablet Refills:0 2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN headache 3. Acyclovir 400 mg PO Q12H 4. Gummies Children Multivitamin (pediatric multivitamin no.30) 1 tablet oral DAILY 5. Lidocaine 5% Patch 1 PTCH TD QPM 6. Lidocaine Viscous 2% 15 mL PO TID:PRN mouth discomfort 7. LORazepam 0.5-1 mg PO Q4H:PRN nausea anxiety insomnia 8. ___ ___ UNIT PO Q6H 9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ============== high grade B cell lymphoma Secondary diagnosis: ================ low back pain neutropenia thrush Hx of PICC associated DVT (___). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a privilege caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were admitted because you were having back pain and a fever WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given medications to help with your back pain - You had an ultrasound done of your arm that showed the clot in your vein had gotten better WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best. Sincerely, Your ___ Team Followup Instructions: ___
19824245-DS-26	19,824,245	29,916,373	DS	26	2179-01-18 00:00:00	2179-01-18 17:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___ Chief Complaint: L groin pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with high grade B-cell lymphoma s/p da-EPOCH-R x 6 cycles and prophylactic IT MTX x 3 doses complicated by RUE PICC-associated DVT and L2/3 compression fracture s/p kyphoplasty who presents with left inguinal pain. Patient reports 1 week of atraumatic left groin pain which occasionally radiates down her left leg. She has no difficulty walking. The pain is not worse with movement. The pain is constant. She has been taking alternating Tylenol and ibuprofen which helps initially but then the pain returns. She describes it is as "cramping" and "shooting". She has no dysuria or hematuria. She did have her first period in 6 months about 2 weeks ago and so she initially thought that it was endometrial pain but the pain persisted which makes her think is less likely to be that. Her end-of-treatment PET:6 on ___ demonstrated marked improvement of disease in all areas, but with persistent FDG-avidity in a multiloculated cystic and solid pelvic mass. She had a pelvic MRI on ___ which showed extensive deep infiltrating endometriosis with overall increased fibrosis and obliteration of the posterior cul-de-sac and tethering of the bowel. She was seen by Gynecologic Oncology and ___ and was decided to defer biopsy. She had repeat PET scan on ___ which showed stable retroperitoneal and mesenteric adenopathy without increased FDG-avidity, ___ 1. However, it also identified new bilateral adnexal, oblong, tubular-like cystic ametabolic structures, with lack of FDG-avidity and shape making hydrosalpinx likely for which pelvic MRI was recommended. She was scheduled to have the MRI on ___. On arrival to the ED, initial vitals were 97.0 112 111/64 22 98% RA. Exam was unremarkable. Labs were unremarkable. UA was positive. Urine culture was sent. Pelvic x-ray was negative for fracture. Pelvic ultrasound showed large complex cystic structures within the bilateral adnexa. MRI pelvis was performed with read pending. Patient was given ceftriaxone 1g IV and 1L NS. Prior to transfer vitals were 98.3 72 108/68 16 98% RA. On arrival to the floor, patient reports ___ left pelvic pain. She denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: - ___: pelvic MRI showed splenomegaly and enlarged lymph nodes involving the mesentery, retropecotral and periportal space. Chest CT showed bilateral axillary lymphadenopathy, no significant mediastinal lymphadenopathy, and confirmed splenomegaly 13.6 cm, and multiple enlarged gastrohepatic and ___ lymph nodes. - ___: ultrasound guided right axillary lymph node needle core biopsy which showed follicular lymphoma, low grade. The immunostaining showed the B cells positive for CD20, CD10, BCL-2, and BCL-6. Ki-67 showed a proliferative index of 15%. - ___: Recommendation for expectant management with a 3 month follow-up CT for low grade lymphoma was made; she did not keep her appointments. - ___: ___ with nausea. CT showed: 1. interval increase in size and number of numerous enlarged mesenteric, retroperitoneal, and ___ lymph nodes in addition to interval enlargement of the spleen is concerning for lymphoproliferative disorder. 2. Complex multiloculated cystic right adnexal lesion measuring 19 x 13 x 15 cm mildly increased in size from prior study (15 x 12 x 14 cm). Interval enlargement and extrinsic compression of the sigmoid colon against the sacrum are likely contributing to the patient's increasing constipation and abdominal distension. - ___: Initial visit to Gyn Onc for eval of adnexal mass. Plan for laparascopic surgical evaluation. Reported difficulty with eating, bloating, unintentional 10 lb weight gain. She denies n.v, pelvic pain, abnormal bleeding, vaginal discharge, or change in her bladder habits. - ___: Patient rescheduled surgery to ___. - ___: ED for abdominal pain, resolved without intervention. - ___: Admission for ex lap. - ___: Exploratory laparotomy, bilateral ovarian cystectomies performed. Diagnosis: Bilateral ovarian endometriomas and pelvic endometriosis. Biopsies sent. C/b post-op ileus. - ___: Hem/pathology of ovary tissue: HIGH GRADE B-CELL LYMPHOMA; SEE NOTE. By immunohistochemistry, the abnormal lymphoid cells are positive for CD20 and CD10 and BCL6 and are negative for MUM1. CD3 and CD5 highlight a small population of admixed T cells. BCL2 diffusely stains both B-cells and T-cells. CD21, CD23 and BCL1 are negative. By Ki-67 immunostaining, the proliferation index approaches 100%. In-situ hybridization for ___ virus encoded RNA ___ ISH) is negative. Epithelial membrane stain is negative. Taken together, the findings are in keeping with involvement by a high grade B cell lymphoma with a germinal center (GC) phenotype. The morphologic features are those of a diffuse large B cell lymphoma. - ___: Cytogenetics: FISH: POSITIVE for IGH/BCL2, IGH/MYC and GAIN of BCL6. C/w Double Hit Lymphoma. - ___: Admission for n/v. Likely ileus, treated conservatively with resolution. - ___: Initial outpatient evaluation by Dr. ___, NP. Recommendation for admission to begin da EPOCH-R that day, but ___ refuses admission. - ___: Staging PET reveals extensive FDG avid left supraclavicular, bilateral axillary, mesenteric, portocaval, retroperitoneal, and left inguinal adenopathy, as well as low right pelvis FDG avidity possibly indicative of bowel involvement by lymphoma, and multiple foci of FDG avidity in the bones, including the right iliac bone and the sternum. - ___: Baseline TTE reveals an LVEF of 50-55%. - ___: C1D1 da-EPOCH-R, dose level 1, uncapped vincristine. - ___: Prophylactic intrathecal methotrexate, dose 1. - ___: C2D1 da-EPOCH-R, dose level 2, uncapped vincristine. - ___: Prophylactic intrathecal methotrexate, dose 2. - ___: C3D1 da-EPOCH-R, dose level 3, uncapped vincristine. - ___: Prophylactic intrathecal methotrexate, dose 3. - ___: C4D1 da-EPOCH-R, dose level 4, uncapped vincristine. - ___: Admitted for low back pain, neutropenic fever, and thrush. Right UENIs show resolution of thrombosis, and therefore enoxaparin is discontinued. - ___: Admitted with low back pain, found to have L2/L3 compression fracture. - ___: PET for evaluation of back pain reveals continued decrease in retroperitoneal and mesenteric lymphadenopathy, now with low level FDG uptake, as well as similar appearance of a large multiloculatic cystic and solic mass in the cul-de-sac, with a focus of FDG-avidity at the posterior aspect demonstrating an SUVmax of 11.7. - ___: MRI of the lumbar spine reveals a new mild L2 and moderate L3 acute/subacute compression fractures, as well as a 6 cm adnexal abnormality, in central location superior to the uterus and right adnexa. - ___: Undergoes kyphoplasty to L2/L3. - ___: C5D1 da-EPOCH, dose level 4, vincristine capped at 0.15 mg/m2/day (total dose 0.8 mg). - ___: Dose 5 rituximab. - ___: Discharged to home. - ___: C6D1 da-EPOCH-R, dose level , vincristine capped at 0.15 mg/m2/day (total dose 1.2 mg). - ___: Dose 6 rituximab. - ___: End-of-treatment PET:6 reveals marked improvement in all areas of disease, but with persistent FDG-avidity in large, multiloculated pelvic mass. - ___: Referred to Dr. ___ Gynecology ___ and Dr. ___ Interventional ___ for consideration of biopsy of the FDG-avid pelvic mass. - ___: MRI of the Pelvis shows endometriosis and endometriomas in the posterior uterine cul-de-sac. Therefore, after discussion with Dr. ___ Gynecologic ___ and Dr. ___ Interventional ___ it was decided not to pursue biopsy of these lesions. - ___: Surveillance PET reveals stable retroperitoneal and mesenteric adenopathy without increased FDG-avidity, ___ 1. However, it also identifies new bilateral adnexal, oblong, tubular-like cystic ametabolic structures, with lack of FDG-avidity and shape making hydrosalpinx likely. Re-evaluation with pelvic MRI is therefore recommended. PAST MEDICAL HISTORY: - "Double Hit" High-grade B-cell lymphoma, as above - Post-LP Headache vs. Arachnoiditis - Right Upper Extremity Thrombosis - L2-L3 Compression Fracture s/p kyphoplasty - Endometriosis Social History: ___ Family History: Denies a known family history of breast, ovarian, uterine, cervical, or colon malignancy. Father with MI. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.9, BP 107/84, HR 82, RR 18, O2 sat 99% RA. GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally. ABD: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema. MSK: No left inguinal tenderness to palpation. Normal LLE ROM. NEURO: A&Ox3, good attention and linear thought, gross strength and sensation intact. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM: GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally. ABD: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema. MSK: No left inguinal tenderness to palpation. Normal LLE ROM. Pertinent Results: ADMISSION LABS: =============== ___ 06:02PM GLUCOSE-89 UREA N-10 CREAT-0.6 SODIUM-141 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 ___ 06:02PM estGFR-Using this ___ 06:02PM ALT(SGPT)-9 AST(SGOT)-9 ALK PHOS-89 TOT BILI-0.3 ___ 06:02PM LIPASE-20 ___ 06:02PM ALBUMIN-4.9 CALCIUM-10.3 PHOSPHATE-3.9 MAGNESIUM-2.1 ___ 06:02PM WBC-4.3 RBC-4.12 HGB-11.2 HCT-34.9 MCV-85 MCH-27.2 MCHC-32.1 RDW-12.7 RDWSD-38.8 ___ 06:02PM NEUTS-76.1* LYMPHS-15.5* MONOS-6.1 EOS-1.4 BASOS-0.7 IM ___ AbsNeut-3.23 AbsLymp-0.66* AbsMono-0.26 AbsEos-0.06 AbsBaso-0.03 ___ 06:02PM PLT COUNT-221 ___ 06:02PM ___ PTT-32.4 ___ ___ 05:47PM URINE HOURS-RANDOM ___ 05:47PM URINE UCG-NEGATIVE ___ 05:47PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:47PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-LG* ___ 05:47PM URINE WBCCLUMP-MANY* MUCOUS-RARE* REPORTS: =============== ___ PELVIS XR No acute fracture or dislocation seen. ___ PELVIS US 1. Transvaginal ultrasound was deferred due to patient preference. 2. Large complex cystic structures within the bilateral adnexa are indeterminately characterized by transabdominal ultrasound. Further evaluation with dedicated pelvic MRI is recommended for characterization. 3. The endometrium is heterogeneously thickened and measures 14 mm, without evidence of internal vascularity. ___ PELVIS MRI IMPRESSION: Interval progression of deep infiltrating endometriosis with increasing endometriomas, hematosalpinx, and new large left hydrosalpinx measuring up to 11.7 cm and exerting mass effect on the pelvic structures. No suspicious enhancing lesion and no suspicious adenopathy. DISCHARGE LABS: ================ ___ 09:15AM BLOOD WBC-4.1 RBC-3.71* Hgb-10.2* Hct-31.4* MCV-85 MCH-27.5 MCHC-32.5 RDW-12.6 RDWSD-38.1 Plt ___ ___ 09:15AM BLOOD Glucose-97 UreaN-10 Creat-0.5 Na-141 K-4.3 Cl-105 HCO3-25 AnGap-11 ___ 09:15AM BLOOD ALT-7 AST-8 AlkPhos-75 TotBili-0.3 ___ 09:15AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.9 Brief Hospital Course: Ms. ___ is a ___ female with high grade B-cell lymphoma s/p da-EPOCH-R x 6 cycles and prophylactic IT MTX x 3 doses complicated by RUE PICC-associated DVT and L2/3 compression fracture s/p kyphoplasty who presents with left inguinal pain in the setting of endometriosis and hydrosalphinx. TRANSITIONAL ISSUES: ======================= [] She will have close OBGYN f/u for infiltrating endometriosis and hydrosalpinx [] Urine culture pending at time of discharge ACUTE ISSUES: ======================= # Left Inguinal Pain: She presented with 1 week of atraumatic left groin pain which occasionally radiates down her left leg. She has been taking Tylenol which reduces the pain to about a 2. She did have her first period in 6 months about 2 weeks ago and so she initially thought that it was endometrial pain. Her end-of-treatment PET CT on ___ demonstrated marked improvement of disease in all areas, but with persistent FDG-avidity in a multiloculated cystic and solid pelvic mass. She had a pelvic MRI on ___ which showed extensive deep infiltrating\ endometriosis with overall increased fibrosis and obliteration of the posterior cul-de-sac and tethering of the bowel. She was seen by Gynecologic Oncology and ___ and was decided to defer biopsy. She had repeat PET scan on ___ which showed stable retroperitoneal and mesenteric adenopathy without increased FDG-avidity, ___ 1. However, it also identified new bilateral adnexal, oblong, tubular-like cystic ametabolic structures, with lack of FDG-avidity and shape making hydrosalpinx likely for which outpatient pelvic MRI was scheduled. She subsequently presented to the ED with groin pain as above and underwent pelvic MRI in the ED which was notable for interval progression of deep infiltrating endometriosis with increasing endometriomas, hematosalpinx, and new large left hydrosalpinx measuring up to 11.7 cm and exerting mass effect on the pelvic structures. OB/Gyn was consulted and felt that there was no indication for acute intervention. Her pain remained well-controlled on Tylenol. Plan was made for discharge home with close outpatient ob-gyn follow-up (scheduled for ___. # Positive UA She initially received ceftriaxone in the ED given WBC on UA. This was subsequently discontinued in the absence of any urinary symptoms including dysuria, urinary urgency or frequency. Urine culture pending with NGTD at time of discharge. # High Grade B-Cell Lymphoma Currently no evidence of active disease per most recent clinic note by Dr. ___ ___. She has follow-up scheduled with him in ___. - Continued home acyclovir CODE: Full Code (presumed) EMERGENCY CONTACT HCP: ___ (mother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Vitamin D 1000 UNIT PO DAILY 3. Calcium Carbonate 1000 mg PO DAILY 4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild 5. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 6. Multivitamins 1 TAB PO DAILY 7. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild 2. Acyclovir 400 mg PO Q12H 3. Calcium Carbonate 1000 mg PO DAILY 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate 5. Multivitamins 1 TAB PO DAILY 6. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 7. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: endometriosis, hydrosalpinx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had Left groin pain. You underwent an MRI of the pelvis. This demonstrated that you have endometriosis as well as fluid in the fallopian tube. This is most likely the cause of your pain. We discussed these results with the ob-gyn doctors. ___ would like to see you in clinic for follow-up. You were felt to be safe to leave the hospital and go home in the mean time. It was a pleasure taking care of you! Your inpatient oncology team Followup Instructions: ___
19824312-DS-6	19,824,312	23,519,754	DS	6	2140-11-06 00:00:00	2140-11-28 09:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine / Barium Iodide / calcium channel blockers / ACE Inhibitors Attending: ___. Chief Complaint: Abdominal Pain Bloody diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with PMHx of HTN, CKD stage IV, HTN, HLD, anemia, and UGIB presents with one day history of bloody diarrhea x 4 episodes. The blood is pale red or maroon per pt. He also has abdominal pain in the epigastric area which is constant and burning. He denies having something like this in the past, although atrius records are notable for history of UGIB entered in ___. Another note mentions a history of "stomach ulcers" and h. pylori infection. Denies fever. He has not had any recent travel or eaten any unusual foods. Last colonoscopy was almost ___ yrs ago per patient and was normal. In the ED, initial vs were: 98.8 96 127/97 16 98% ra. Labs were remarkable for Cr of 2.9 (baseline 2.0) and Hct of 37.7 (baseline 33). BP lowest at 93/58 without tachycardia. EKG showed LAD without ischemic changes. Patient was given 1L NS and 2 large bore IVs were placed. He was typed and screened and started on PPI gtt. Vitals on Transfer: 73 ___ 99%. On the floor, vs were wnl and pt complained of ___ abdominal pain and feeling dizzy. He reported that his last episode of bloody diarrhea was at 4 or 5pm yesterday. Past Medical History: Hypercholesterolemia Gout VARICOSE VEINS PEPTIC ULCER, UNSPEC ANEMIA, UNSPEC HELICOBACTER PYLORI INFECTION Colonic adenoma Asthma EDEMA - PERIPH Hypertension, essential, benign IMPOTENCE DUE TO ERECTILE DYSFUNCTION Vitamin B12 deficiency without anemia VITAMIN D DEFIC, UNSPEC GASTROINTESTINAL BLEEDING - UPPER TINNITUS, UNSPEC Weight loss Chronic kidney disease, stage IV (severe) Macrocytosis Hyperparathyroidism due to renal insufficiency Eczema Gynecomastia, male Asthma Olecranon bursitis of left elbow Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: 97.6, 150/90, 85, 18, 100% on RA General: comfortable appearing ___ man in NAD HEENT: NCAT. MMM. EOMI. PERRL Neck: supple Lungs: ctab, no w/r/r CV: RRR, no w/r/r Abdomen: pt is exquisitely tender to palpation of the epigastric area with positive guarding and rebound. hyperactive bowel sounds. rectal exam is negative for blood, stool, or masses. Ext: no edema. 2+ pulses Skin: no lesions or bruising Neuro: CNs grossly intact, MAEE Discharge Physical Exam: VS 98 70 141/90 18 100% RA GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclear were slightly icteric, OP clear NECK supple,JVD 2 cm above clavicle, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD Midline scar, mildly distended from baseline, no tap or shake tenderness, soft, normoactive low-pitched bowel sounds, no focal tenderness but epigastric and RLQ guarding on deep palpation. No abdominal bruits appreciated. Rectal: No gross blood on DRE. No stool in rectal blood. No perianal lesions or external hemorrhoids. Guaiac negative. EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN multiple hyperpigmented macules with ulcerated centers from prior eczema lesions Pertinent Results: Admission Labs -------------- ___ 12:35AM BLOOD WBC-8.4 RBC-3.88* Hgb-13.0* Hct-37.7* MCV-97 MCH-33.5* MCHC-34.4 RDW-13.6 Plt ___ ___ 12:35AM BLOOD Neuts-73.6* ___ Monos-5.6 Eos-2.2 Baso-0.3 ___ 12:35AM BLOOD Plt ___ ___ 12:35AM BLOOD Glucose-121* UreaN-28* Creat-2.9* Na-135 K-3.9 Cl-98 HCO3-22 AnGap-19 ___ 12:35AM BLOOD ALT-17 AST-24 AlkPhos-55 TotBili-0.8 ___ 05:09AM BLOOD Lipase-41 ___ 05:09AM BLOOD cTropnT-<0.01 ___ 05:09AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.6 Cholest-234* ___ 05:09AM BLOOD Triglyc-107 HDL-64 CHOL/HD-3.7 LDLcalc-149* ___ 05:20AM BLOOD Lactate-0.9 Discharge Labs -------------- ___ 10:10AM BLOOD WBC-4.9 RBC-3.61* Hgb-12.0* Hct-36.2* MCV-100* MCH-33.1* MCHC-33.1 RDW-13.2 Plt ___ ___ 10:10AM BLOOD Plt ___ ___ 10:10AM BLOOD Glucose-110* UreaN-15 Creat-1.7* Na-139 K-4.2 Cl-106 HCO3-24 AnGap-13 Imaging -------------- ABDOMEN (SUPINE & ERECT) ___: IMPRESSION: Mild dilatation of the small and large bowel suggestive of functional ileus. CT ABD & PELVIS W/O CONTRAST ___: IMPRESSION: 1. Dilatation of the distal common bile duct without evidence of stone. 2. Small fat containing left inguinal hernia. 3. Degenerative disease of the lumbar spine. Microbiology -------------- None Brief Hospital Course: ___ with PMHx of HTN, HL, CKD stage IV,and reportedly UGIB (duodenal s/p resection) presents with bloody diarrhea likely from LGIB (hemorrhoidal bleed vs AVM) and ___. #Bloody diarrhea: The patient was admitted with abdominal pain and four episodes of bright red diarrhea concerning for a lower GI bleed. On admission, the patient was hemodynamically stable and had a Hct (mid ___, unknown baseline) that was stable throught the hospitalization. KUB was notable for mildly dilated bowel loops but unremarkable for bowel perforation or obstruction. The patient was guaiac negative. Given the patient's vascular risk factors, ischemic colitis was initially suspected. Lactate was 0.9. The patient was managed conservatively with bowel rest, IV fluids, high dose PPI, and pain medication. An abdominal CT was performed and no evidence of bowel wall thickening or ischemic changes were apparent. Given the patient's history of hemorrhoids, the patient's LGIB was attributed to hemorrhoidal bleed or AVMs. The patient was discharged with plans for followup with his outpatient gastroenterologist for possible flexible sigmoidoscopy/colonoscopy. At the time of discharge, the patient's abdominal pain improved and had no repeat episodes of bloody diarrhea. # Acute kidney injury: On admission, the patient's Cr was 2.9 (baseline Cr 1.9-2.3). This was likely secondary to prerenal azotemia in the setting of hypovolemia from poor PO intake and diarrhea. During this hospitalization, the patient receieved a total of 3 L NS. The patient' home irbesartan were held. At the time of discharge, the patient's Cr was 1.7 and irbesartan restarted. #Chronic Conditions: #Dyslipidemia: Patient has a hx of dyslipidemia but was not on a statin at the time of admission. Lipid panel during this hospitalization was notable for cholesterol:234 and LDL:149. A statin was not started # HTN: Was stable throughout hospitalization. The patient's home irbesartan was for in the setting of ___. # Asthma: Stable throughout hospitalization. The patient was continued on home Flovent. Transitional Issues: -------------------- [ ] Gastroenterologist followup with Atrius Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyclobenzaprine ___ mg PO HS:PRN neck pain hold for oversedation 2. Cyanocobalamin 1000 mcg IM/SC QMONTHLY 3. irbesartan NF 300 mg Oral daily 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 6. Fluticasone Propionate 110mcg 2 PUFF IH BID Discharge Medications: 1. Fluticasone Propionate 110mcg 2 PUFF IH BID 2. Fluticasone Propionate NASAL 1 SPRY NU DAILY 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 4. Cyanocobalamin 1000 mcg IM/SC QMONTHLY 5. Cyclobenzaprine ___ mg PO HS:PRN neck pain 6. irbesartan NF 300 mg Oral daily Discharge Disposition: Home Discharge Diagnosis: Lower gastrointestinal bleed Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the ___ because you had abdominal pain and four episodes of bloody diarrhea. At the time of admission your blood pressure and hematocrit levels were found to be normal and stable making a heavy bleed unlikely. An xray of your abdomen showed no bowel perforation but did show dilated bowel loops consistent with slowed bowel movement called an ileus. A CAT scan determined that you do not have any concerning problems with your bowel. You were treated with bowel rest, IV fluids, and pain medication. Given your history of an ulcer, you were also treated with a medication to reduce your stomach acid levels. Your symptoms improved with this regimen. We think you bleeding may have been due to abnormal blood vessels in your colon or hemorrhoids, and you will be scheduled to see a gastroenterologist within 14 days. Please take your discharge medications as instructed. You are scheduled for followup with your primary care physician and gastroenterologist. Your gastroenterologist will determine whether you will need to have a colonoscopy. It was a pleasure taking care of you. Followup Instructions: ___
19824550-DS-15	19,824,550	20,475,252	DS	15	2192-03-06 00:00:00	2192-03-06 14:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) / Bactrim DS Attending: ___. Chief Complaint: Small Bowel Obstruction Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with hx NHL s/p chemotherapy and radiation therapy completed in ___ of this year who also has history of chronic, recurrent abdominal pain. She now presents with malaise and possible partial small bowel obstruction on KUB. She began feeling abdominal pain and bloating 3 nights ago after eating. Since that time she has had several episodes and continued pain in lower quadrants b/l. She doesn't recall flatus or recent bowel movement. Of note, her past history of lymphoma had significant involvement in abdominal/retroperitoneal nodes. Past Medical History: PMH: 1. Non Hodgkin's lymphoma, s/p chemo (___) rads (___) 2. Asthma 3. hypothyroid PSH: 1. Pinning of right hip fracture 2. Detached retina and cataract surgery. 3. History of colonic polyps and diverticula 4. Chronic abd pain w mutiple provider/ED visits over past ___ 5. Total abdominal hysterectomy for unknown indication 6. multiple BCC excisions Social History: ___ Family History: Non-contributory Physical Exam: Vitals: 99.2 98.7 113 139/79 18 98% Gen: AOx3 NAD Cor: RRR without MRG Res: CTAB Abd: Soft but quite distended, tympanitic, mild ttp in lower quadrants bilaterally Ext: WWP without edema Neuro: Without focal deficit MSK: strength symemtric bilaterally in upper and lower Psych: Normal mood appropriate affect Vasc: Palpable DP bilaterally Pertinent Results: ___ 12:24PM ___ PTT-26.4 ___ ___ 10:40AM GLUCOSE-223* UREA N-29* CREAT-1.0 SODIUM-137 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-20 ___ 10:40AM ALT(SGPT)-28 AST(SGOT)-23 ALK PHOS-87 TOT BILI-0.6 ___ 10:40AM LIPASE-15 ___ 10:40AM WBC-6.2 RBC-4.67 HGB-14.5 HCT-41.8 MCV-89 MCH-31.1 MCHC-34.8 RDW-13.6 Brief Hospital Course: Patient was admitted to the ___ service on ___ with concern for small bowel obstruction. She was made NPO, put on IV fluids, and an NG tube was placed. On ___ she began to pass flatus and have return of bowel function. Her NG tube output decreased to approx 100cc over 8 hours, and it was discontinued in the afternoon. She was started on a clear liquid diet which she tolerated well. On ___ she was advanced to a regular diet, and her IV fluids were discontinued. Her abdominal pain had resolved, and she continued to have appropriate bowel function. She was deemed appropriate for discharge at this time. Medications on Admission: 1. ALBUTEROL SULFATE 90 mcg/actuation 2 puffs Inh BID 2. ATORVASTATIN - 20 mg tablet PO Daily 3. FLUTICASONE -50 mcg/actuation 1 -2 puffs BID 4. FLUTICASONE - 50 mcg/actuation for Inhalation BID 5. LEVOTHYROXINE 50 mcg tablet Daily 6. TRAMADOL - tramadol 50 mg tablet PO BID 7. CALCIUM CITRATE-VITAMIN D3-200-250 3 tabs daily 8. CHOLECALCIFEROL (VITAMIN D3) 1,000 unit capsule daily Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Atorvastatin 20 mg PO DAILY 4. Albuterol Inhaler 2 PUFF IH BID PRN SOB 5. Fluticasone Propionate NASAL 2 SPRY NU BID 6. TraMADOL (Ultram) 50 mg PO BID 7. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ___ service for a small bowel obstruction. You have had return of bowel function, can tolerate a regular diet, and are ready to return home. Please call your doctor or go to the emergency department if: You experience new chest pain, pressure, squeezing or tightness. You develop new or worsening cough, shortness of breath, or wheeze. You are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. Your pain is not improving within 12 hours or is not under control within 24 hours. Your pain worsens or changes location. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Followup Instructions: ___
19824938-DS-21	19,824,938	22,027,395	DS	21	2169-12-15 00:00:00	2169-12-15 22:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Nausea, diarrhea, abdominal cramps x 4 days. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ year-old woman with no PMH who presented with nausea, diarrhea, and abdominal cramps. For the 4 days PTA, the patient had constant nausea and watery diarrhea without vomiting. Diarrhea was liquid, but non-bloody. She had up to 10 BMs a day. On ___, the night prior to presentation, she was unable to sleep because she had 10 BMs overnight. She reports the volume of BM is associated with amount of PO intake. She denied tenesmus or rectal pain. She denied sick contacts or recent travel, but she did finish a course of amoxicillin 3 weeks PTA for URI. On the day PTA, she developed ___ crampy, lower abdominal pain. It was intermittent in nature, with no radiation to back or grown. She denied vaginal bleeding or discharge. Her last menstrual period was 3 weeks ago and she is not sexually active. She endorses break-through bleeding for the past few days. She went to her ___ who referred her to ED for dehydration. In the ED, vital signs were: Temp: 97.6 HR: 76 BP: 127/78 RR: 16 O2Sat: 98. Exam showed soft abdomen with diffuse tenderness to palpation. Stool was guaiac negative. Pelvic exam showed friable cervix with some bleeding. Lytes normal, lipase negative, AST to 78, hCG negative, UA negative. GC and chlamydia swab were sent. Stool c diff was not sent as Ms. ___ had not had a BM since ___ am on ___ when she presented. CT abdomen showed ascending colonic colitis, infectious vs inflammatory, and mild hepatic steatosis. She was admitted to medicine for observation while not tolerating PO intake and further workup of colitis. On the floor, vs were: 98.3 100/52 72 20 99% on RA. She was c/o ___ abdominal pain, but denied nausea, vomiting, or any BM since presenting to the ED. Review of sytems: (+) Per HPI (-) Denied fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: None. Social History: ___ Family History: CAD in father. ___ family history of IBD or other autoimmune diseases. Physical Exam: ADMISSION PHYSICAL EXAM ================== PHYSICAL EXAM: Vitals- 98.3 100/52 72 20 99% on RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non distended, TTP in lower abdomen with some guarding, no rebound tenderness Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM ================== Vitals: Tm: 99 BP: 120/68 P: 75 R: 16 O2:99RA No loose BMs overnight General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly TTP at RLQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No rashes or lesions Neuro: CNII-XII grossly intact Pertinent Results: ADMISSION LABS =========== ___ 01:15PM BLOOD WBC-7.8 RBC-4.53 Hgb-13.7 Hct-40.4 MCV-89 MCH-30.2 MCHC-33.8 RDW-12.2 Plt ___ ___ 01:15PM BLOOD Neuts-73.9* ___ Monos-5.6 Eos-0.9 Baso-0.9 ___ 01:15PM BLOOD Plt ___ ___ 01:15PM BLOOD Glucose-90 UreaN-8 Creat-0.7 Na-137 K-4.3 Cl-100 HCO3-26 AnGap-15 ___ 01:15PM BLOOD ALT-39 AST-78* AlkPhos-56 TotBili-0.4 ___ 01:15PM BLOOD Albumin-4.5 ___ 01:15PM BLOOD CRP-33.5* MICRO ===== Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis NEISSERIA GONORRHOEAE (___), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae DISCHARGE LABS =========== ___ 06:00AM BLOOD WBC-5.7 RBC-4.28 Hgb-12.8 Hct-38.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.1 Plt ___ ___ 06:00AM BLOOD Glucose-80 UreaN-5* Creat-0.7 Na-139 K-4.3 Cl-103 HCO3-27 AnGap-13 ___ 06:00AM BLOOD Phos-2.9 Mg-1.9 ___ 06:00AM BLOOD ALT-25 AST-30 AlkPhos-54 TotBili-0.4 ___ 06:50AM BLOOD TSH-2.5 IMAGING ======= CT A/P ___. Ascending colonic colitis. These findings are likely of infectious or inflammatory etiology, and less likely ischemic pathology. No evidence of perforation or definite terminal ileal involvement, though assessment of the terminal ileum is slightly limited due to underdistention. 2. Mild hepatic steatosis. Brief Hospital Course: ACTIVE ISSUES # Abdominal pain/diarrhea: The patient presented with 4 days of nausea, watery diarrhea with ___ BM/day, and 1 day abdominal cramps. In terms of differential, gynecologic, gastrointestinal, and genitourinary causes were considered. HCG negative. GC/chlamydia negative. Pelvic exam was notable only for friable cervix, likely related to withdrawal bleeding from being unable to take much PO. CT of the abdomen and pelvis was only notable for ascending colitis and mild hepatic steatosis. Taken together, this made gynecologic causes as well as genitourinary causes for her pain unlikely. In terms of gastrointestinal causes, she denied any sick contacts. She noted that she had eaten cafeteria food with friends for the few days PTA, none of whom had fallen ill, arguing against food poisoning. Given her recent amoxicillin course, C. diff colitis was considered, but without fever, leukocytosis, or diarrhea while in the hospital, this seemed unlikely. Viral gastroenteritis was therefore thought to be the most likely diagnosis. An initial IBD flare remained possible, and her age was appropriate for a first flare; however, the rapid and severe onset of colitis argue against this (less than 1% of first IBD flares are severe with 10 BM/day). During her stay, she was initially NPO and treated with supportive care, including IVF, zofran, and oxycodone for pain. Her diet was slowly advanced, which she tolerated without increase in abdominal pain, vomiting, or diarrhea. She was discharged home with instructions to follow-up with her PCP ___ ___ weeks. CHRONIC ISSUES None. TRANSITIONAL ISSUES - The patient mentioned that she had been told by a homeopathic physician that she has ___'s thyroiditis. She has not ever been treated for this. She denied any excessive sleep, cold intolerance, weight gain, and said that the low thyroid function test was in the setting of mononucleosis. However, existence of other autoimmune disorder would make IBD more likely, so TSH was checked and measured 2.5, within normal limits. - Follow-up TSH level should be done as an outpatient, not in the setting of an acute illness, to determine true level. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Necon 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35 mg-mcg oral daily 2. Ibuprofen 400 mg PO Q8H:PRN pain Discharge Medications: 1. Ibuprofen 400 mg PO Q8H:PRN pain 2. Necon 0.5/35 (28) (norethindrone-ethin estradiol) 0.5-35 mg-mcg oral daily Discharge Disposition: Home Discharge Diagnosis: Primary: - Viral gastroenteritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted with abdominal pain and diarrhea. We did a number of tests to determine the source of your symptoms. Your CT scan showed inflammation in your colon, but no other specific abnormalities. We believe that your symptoms are likely related to a non-specific viral gastroenteritis. Followup Instructions: ___
19825332-DS-5	19,825,332	24,364,235	DS	5	2177-08-22 00:00:00	2177-08-23 06:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness, sensory changes Major Surgical or Invasive Procedure: ___ placement ___ Exploratory Laparotomy ___ Lumbar puncture Bone marrow biopsy History of Present Illness: Mr. ___ is a ___ with no significant PMH who presents with one day of intractable bilious vomiting, 6 days of constipation, and a few weeks of bilateral 4 extremity weakness. ACS is consulted for potential SBO versus ileus. Three weeks ago, he had a few episodes of vomiting followed by progressive muscle weakness in his arms and his legs. He states that he had at least ___ episodes of vomiting over two days which then stopped, and his weakness began at that time. He presented most recently to the ED for this upper and lower extremity weakness and was admitted to the Neurology service for further workup. He has been experiencing similar symptoms of weakness with associated vomiting intermittently for the past year and a half. Although there is no consistent temporal relationship between the vomiting and the weakness (such as weakness followed by vomiting or vice versa) the two symptoms do tend to occur within days of each other. These symptoms typically last a few weeks at a time, and get better on their own. He is being extensively worked up by the Neurology service for multiple diagnoses, including porphyria and other neuromuscular disorders. Upon evaluation, Mr. ___ endorses some epigastric pain and nonstop vomiting beginning ___. He has not had a bowel movement for 6 days, but he does endorse passing gas. He also has weakness of his arms, worse distally than proximally, and much more severe weakness of his lower extremities bilaterally. He denies changes in his urine color, dysuria, urinary retention, headache, chills, fevers, chest pain, or SOB. Past Medical History: PMH: Hypertension PSH: Open appendectomy at age ___ Open ___ repair ___ years ago Social History: ___ Family History: Mother with RA Physical Exam: ADMISSION EXAM ============== Vitals: T: 97.9 P: 98 r: 16 BP: 142/63 SaO2: 100% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W. Counts 41 in one breath. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Neck flexion and extension ___ bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 5 ___ ___ 2 3 3- 4 4 R 5 ___- ___ 2 3 3- 4 4 -Sensory: Pinprick examination was somewhat inconsistent, he initially reported what seemed to be a spinal level at about T5 but on re-testing this was not apparent. There is decreased pinprick sensation in a circumferential pattern below the knees. Vibration and joint position are greatly reduced below the knees. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 1 0 1 tr 0 R 1 0 1 tr 0 Plantar response was mute bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Not tested due to weakness. DISCHARGE EXAM: =============== VS: Temp: 98.5 (Tm 99.3), BP: 131/85 (70-145/6-91), HR: 86 (77-86), RR: 20 (___), O2 sat: 100% (94-100), O2 delivery: Ra Exam General: Well appearing, well nourished, NAD HEENT: NCAT, no scleral icterus or injection, MMM Heart: RRR, warm extremities Lung: No increased work of breathing Abd: Mildly distended Skin: No rashes, lesions or excoriations Neurological Exam: MS: Awake and alert, attentive, responds to questions appropriately and without difficulty. Speech is fluent with intact comprehension. No paraphasic errors. Able to follow midline and appendicular commands. No signs of neglect. CN: EOMI. No facial asymmetry. Hearing intact to conversation. Motor: Normal tone, bilateral atrophy of lower extremities including EDBs bilaterally. No adventitious movements. No fasciculations. Strength: Normal tone, decreased bulk. Delt Bic Tric WrEx FinEx FDI IO Ham Quad TA Gas R 5 5 4- 5 4 4+ 4 5 5 4 5 L 5 5 5- 4+ 4 5- 5- 5 5 4+ 5 DTRs: ___ this AM Sensation: Deferred this AM Coordination: Deferred this AM Pertinent Results: WORKUP: ======= Anemia Workup: calTIBC: 150 VitB12: 1267 Hapto: 325 Ferritn: 1359 TRF: 115 Neuropathy Workup: CSF: TNC 0, RBC 0, Total protein 53, Glucose 60 amylase 46 lipase 34 Endocrine: TSH 4.7, 5.7 rose to 7.5 Free T4 22 Anti-Tg less than 1 Thyroglobulin 32 Anti TPO 37 A1C 5.0 Heme/Onc: quant porphobilirubin is 1.2 (wnl), collected on ___ prior to hemin treatment ___ spot urine: + porphobil (presumptive) ___ Quant urine: Porphobilinogen (negative) ALA dehydratase 9.4 nmol/L/s (wnl) ALA dehydratase (collected on ___: wnl SPEP: No specific bands, IgM 359 UPEP: negative (only albumin) FreeKap: ___ FreeLam: ___ Fr K/L: 1.1 Paraneoplastic panel CSF and blood: negative Bone marrow biopsy: Cytogenetics and immunophenotyping negative with negative ___ red Neuronal ___: neg Negative PET/CT Inflammatory: CRP 33.9 on admission, rose to 258.9, dropped to 45.9 ESR: 58 b2micro: 3.4* Auto-immune: RF<10, ___ negative Negative NMO Ab GQ1B IgG Ab: <1:100 Sjogren's: neg NMO/Aquaporin-4-IgG: neg C3 157, C4 54 ANCA negative Infectious: Heb B negative, Hep C, HCV PCR negative EBV PCR: neg HIV antibody neg CMV viral load undetectable Arbovirus: negative Coccidioides antibody, CSF negative Enterovirus RT-PCR, CSF negative TB PCR, CSF negative Vitamins Deficiency: B6: wnl B1: wnl Vitamin E: wnl MMA: wnl Other: Copper: 70 heavy metal sreen: neg ace 67 ___ red stain on bone marrow biopsy: negative IMAGING: ======== PET/CT IMPRESSION: 1. No evidence of abnormal FDG uptake in the head, neck, thorax, abdomen, and pelvis. 2. Bilateral mild to moderate hydroureteronephrosis is similar to the prior CT abdomen and pelvis from ___. 3. There is lack of tracer in the left ureter and the bladder, which raises the possibility of obstruction. 4. Bilateral pleural effusions, right greater than left. Renal Ultrasound IMPRESSION: 1. Mild hydronephrosis bilaterally. The right extra renal pelvis is minimally dilated and in the left kidney there is a simple parapelvic cyst measuring 8.5 cm. Overall the appearance of the kidneys is not significantly changed compared to the abdomen CT of ___. 2. The bladder is collapsed on a Foley catheter. MRI head with/without contrast: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is no abnormal enhancement after contrast administration. IMPRESSION: Brain atrophy. No acute infarcts mass effect or hydrocephalus. No etiology identified for persistent lower extremity weakness . MRI spine: FINDINGS: Exam is limited by patient motion. Contrast were images were not obtained due to patient preference. CERVICAL: The cervical spine alignment is normal. Vertebral body and intervertebral disc signal intensity appear normal. The spinal cord appears normal in caliber and configuration. Multilevel degenerative changes are not significantly changed compared with MRI ___, resulting in up to mild canal narrowing and mild to moderate neural foraminal narrowing at multiple levels. No severe spinal canal narrowing. THORACIC: Alignment is normal. There is a Schmorl's node along the superior endplate of T6. T1/T2 hyperintense lesions in the T3 and T10 vertebral bodies are consistent with a hemangiomas. Vertebral body height and marrow signal is otherwise maintained. There is loss of normal T2 disc signal at T4-T5, with a small posterior disc bulge which results in mild spinal canal narrowing. There is otherwise no evidence of significant spinal canal or neural foraminal narrowing. The spinal cord appears normal in caliber and configuration. LUMBAR: Alignment is normal. T1/T2 hyperintense lesions in the L2 and L4 vertebral bodies are consistent with hemangiomas. Vertebral body height and marrow signal is maintained. There is loss of normal T2 disc signal at T12-L1, L2-L3, L3-L4, L4-L5, and S5-S1.The spinal cord appears normal in caliber and configuration. The conus terminates at the L1 level. There is no significant spinal canal or neural foraminal narrowing from T12-L1 to L2-L3. At L3-L4, a small posterior disc bulge results in mild spinal canal and bilateral neural foraminal narrowing. At L4-L5, a small posterior disc bulge results in mild spinal canal and bilateral neural foraminal narrowing. At L5-S1, a posterior disc bulge and facet arthropathy results in mild canal narrowing, moderate right and mild left neural foraminal narrowing. OTHER: There are trace bilateral pleural effusions. There is a 1.4 x 0.6 cm cystic lesion in the posterior left extrapleural fat between the left seventh and eighth ribs, nonspecific (13:37). Again seen is bilateral hydroureteronephrosis, not significantly changed compared with CT abdomen and pelvis on ___. Loculated fluid at the GE junction adjacent to a hiatal hernia is similar to recent CT chest and CT abdomen and pelvis, possibly postsurgical (13:37). A subcutaneous cystic lesion in the posterior neck is unchanged compared with prior MRI, likely a sebaceous cyst. IMPRESSION: 1. Exam is somewhat limited by motion. Contrast images were not obtained due to patient preference. 2. No severe spinal canal narrowing, evidence of cord compression or compression of the cauda equina nerve roots. 3. Multilevel degenerative changes as described. 4. Additional findings as above. EMG ___: ============== FINDINGS: Note that the study was very technically challenging to perform for a multitude of reasons. Motor nerve conduction studies (NCSs) of the right median nerve were normal. Motor NCSs of the right ulnar nerve, recording abductor digiti minimi (ADM), revealed mildly prolonged distal latency, moderately reduced response amplitudes, normal conduction velocity in the forearm and severely reduced conduction velocity (with a drop of 24.7 m/s) across the elbow. Motor NCSs of the right ulnar nerve, recording first dorsal interosseous (FDI), revealed mildly prolonged distal latency, normal distal response amplitude, and normal conduction velocities. A possible ___ Anastomosis could not be confirmed; partial conduction block in the forearm cannot be excluded. Motor responses of the right deep peroneal nerve were absent. Motor NCSs of the right tibial nerve revealed normal distal latency and markedly reduced response amplitudes. Sensory NCS of the right median nerve revealed a moderately reduced response amplitude and moderately slowed conduction velocity. Sensory NCS of the right ulnar nerve revealed a mildly reduced response amplitude and moderately slowed conduction velocity. Sensory response of the right sural nerve was absent. Concentric needle electromyography (EMG) of selected muscles representing the right C5-T1 myotomes was performed. In biceps there was an admixture of short-duration, small-amplitude, polyphasic and mildly long-duration, large-amplitude polyphasic motor unit potentials. In deltoid, triceps, and flexor carpi radialis there was moderate-severe ongoing denervation in the forms of fibrillation potentials and positive sharp waves in addition to an admixture of short-duration, small-amplitude, polyphasic and mildly long-duration, large-amplitude polyphasic motor unit potentials. There was mild chronic reinnervation of first dorsal interosseous. Complex repetitive discharges (CRDs) were noted in several proximal muscles. Concentric needle EMG of selected muscles representing the right L2-S1 myotomes was performed. There was mild chronic reinnervation of tibialis anterior and medial gastrocnemius. Detailed examination of voluntary motor unit potentials was not possible in vastus lateralis, adductor longus, and long head of biceps femoris due to limited activation and the distance of visualized motor unit potentials; however, no ongoing denervation was noted. Bone Marrow Biopsy: =================== Cytogenetics FISH: NEGATIVE MULTIPLE MYELOMA PANEL. No evidence of interphase bone marrow plasma cells with gain of 1q, rearrangement of the IGH gene, deletion 13q14, monosomy 13, deletion of the TP53 gene or gain of chromosomes 5, 9 or 15. This study was performed after magnetic separationto enrich the concentration of plasma cells. Core Biopsy: ============ NORMOCELLULAR BONE MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS By immunohistochemistry performed on the core biopsy, CD3 and CD5 highlights scattered T-cells. CD20 highlights rare scattered B-cells. CD138 highlights plasma cells scattered singly and in small clusters, comprising ___ of the cellularity. Kappa and lambda immunostaing shows increased background staining, precluding the determination of clonality. However, concurrent flow cytometry showed that plasma cells exhibit a polyclonal pattern of light chain expression. A ___ red stain is negative. IMMUNOPHENOTYPING INTERPRETATION: ================================= Non-specific T-cell predominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia/lymphoma or a plasma cell dyscrasia are not seen in this specimen. Correlation with clinical, morphologic (see separate pathology report ___ and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. Brief Hospital Course: PATIENT SUMMARY: ================ This is a ___ year old male with PMH of HTN and alcohol abuse who presented with acute worsening of weakness and paresthesias in the setting of multiple episodes of nausea accompanied by weakness and paresthesia. ACUTE ISSUES: ============= # Sensorimotor Polyneuropathy Initial workup suggestive of acute intermittent porphyria, however confirmatory testing was negative. The etiology of his weakness remains unclear at the time of discharge though he responded well to initial course of IVIG. He had a second course of IVIG during the week of ___ (70 grams x 2 days). The time course of his symptoms makes acute inflammatory demyelinating polyradiculoneuropathy (AIDP) unlikely and EMG was not fully consistent with CIDP. MRI brain, C/T/L spine, CT chest w/ contrast, skeletal survey and PET/CT did not reveal structural etiology of his symptoms. LP was preformed and CSF had slightly elevated protein (53) but was otherwise bland. From a nutritional perspective, copper was borderline low and was repleted without resolution of symptoms. Heavy metal screen was negative. Infectious workup including HIV, arbovirus, CMV, EBV, hep B/C, RPR, coccoides, enterovirus and Tb was negative. Whipple's PCR negative. Malignancy work up including PET/CT, and paraneoplastic panel in blood and CSF unrevealing. However, he had an elevated free and lambda chain and persistent macrocytic anemia not explained by vitamin deficiency. Bone marrow biopsy was negative for leukemia, lymphoma and plasma cell dyscrasia and cytogenetic multiple myeloma panel was negative. ___ red stain was also negative. On exam at the time of discharge to have diffuse, though improved, weakness with distal > proximal weakness in his upper extremities and proximal > distal weakness in his lower extremities. He has notable atrophy of both small and large muscles in upper and lower extremities indicative of some chronicity. Reflexes in upper extremities are returning and his strength is improving after IVIG. Of note, he continued to have orthostasis related to deconditioning and autonomic neuropathy. His antihypertensives were thus decreased later in his hospitalization in order to allow the patient to work with ___ without becoming symptomatic. # Small Bowel Obstruction s/p Exploratory Laparotomy ___ His hospital course was complicated by SBO s/p ex lap revealing small hernia. Small bowel was entrapped adhesions between the redundant loop of sigmoid colon requiring ex lap and adhesion removal. He will need follow up with both general surgery and urology in the outpatient setting. Patient stooling normally at time of discharge. # ___ Patient developed ___ this admission due to acute interstitial nephritis (possibly related to hemin which he received empirically for porphyria) vs. contrast-induced nephropathy now resolved. # Fevers of Unknown Origin # Leukocytosis Of note, he also had intermittent low-grade fevers this admission and a persistent leukocytosis. Infectious workup revealed enterococcus and klebsiella pneumoniae and he received ceftriaxone (14 day course of Ceftriaxone started ___ and ampicillin (12 day course of ampicillin 500 mg IV Q6H started ___ this admission. He was afebrile and with normal WBC at the time of discharge. # Hydronephrosis PET showed asymmetric uptake of tracer in the ureters concerning for obstruction. Urology was consulted and recommended placing foley. Foley subsequently removed and patient voiding on his own at time of discharge without difficulty. Will follow up with urology as an outpatient. # Macrocytic Anemia He had macrocytic anemia throughout this admission and Hgb slowly down-trended to mid 7 range. No active signs of bleeding, most likely secondary to phlebotomy. Vitamin levels are above the lower limit of normal. Bone marrow biopsy was unremarkable. ___ iron labs showed anemia of chronic disease. Hemolysis labs were negative. Reticulocyte count was 4.2. Will continue ferrous sulfate 325 mg PO daily as outpatient. # Hypertension History of hypertension, but has not been on medications for years. Please continue lisinopril 5 mg PO QD as outpatient. # Alcohol Use Disorder Case management consulted for alcohol cessation counseling. Will continue thiamine, B12, multivitamin, folate, Mg as outpatient. TRANSITIONAL ISSUES: ==================== # Patient diagnosed with enterococcus and klebsiella pneumoniae urinary tract infections this admission; completed course of ceftriaxone and ampicillin in the hospital. Please continue to monitor for fevers in the outpatient setting. # Patient with anemia this admission likely due to excessive phlebotomy and anemia of chronic disease. Hgb 7.6 at time of discharge. Continue to monitor anemia with repeat CBC on ___. # Patient with pre-existing hypertension. He was started on multiple anti-hypertensive medications this admission but these were ultimately down-titrated in order to allow for patient to work with ___ due to symptomatic orthostatic hypotension. Please continue to monitor blood pressure and concern for orthostatic hypotension. Consider further up-titration of anti-hypertensive agents in the outpatient setting. # Continue to monitor thyroid function. TSH and free T4 showed subclinical hypothyroidism. Thyroid antibodies were negative. Slightly elevated antiTPO antibodies, non specific. # Patient had elevated PSA this admission 8.3. Continue to monitor. # Third course of IVIG (70 grams per day for 2 days) to be done week of ___. # Continue MVI, thiamine, folate, Mg replacement given history of EtOH use disorder Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 2. Calcium Carbonate 500 mg PO QID:PRN abdominal discomfort 3. Citalopram 20 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 1000 mg PO TID 8. Lidocaine 5% Ointment 1 Appl TP BID:PRN for peripheral pain 9. Lisinopril 5 mg PO DAILY 10. Magnesium Oxide 400 mg PO BID 11. Miconazole Powder 2% 1 Appl TP TID:PRN groin rash 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID:PRN Constipation - First Line 15. Simethicone 40-80 mg PO QID:PRN gas pain 16. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 17. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush 18. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush 19. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 20. Tamsulosin 0.4 mg PO DAILY 21. Thiamine 100 mg PO DAILY 22. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 23. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Sensorimotor polyneuropathy of unknown etiology Anemia Small bowel obstruction ___ Hydronephrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital for vomiting, weakness, and numbness and tingling in your arms and legs. While you were in the hospital, you had an extensive workup which did not reveal the cause of your sensory and strength changes. You received 2 courses of IVIg which significantly improved your strength. We recommend that you receive IVIg every 4 weeks for the next 3 months. Additionally, you will need rehabilitation upon discharge for continued physical and occupation therapy. Your hospital course was complicated early in admission with a small bowel obstruction requiring surgery. You have been tolerating food and having bowel movements since the surgery, but will need to make sure you follow up with general surgery after discharge. Other medical issues noted during this hospitalization are: - Hypertension which required medication to be started - Your blood pressure drops when you stand, this is known as orthostatic hypotension - Anemia - Swelling of your kidneys which needs to be monitored - Urinary tract infection You will need to follow up with following doctors upon ___: - Neuromuscular specialist - General surgery - Urology - Primary care It was a pleasure taking care of you. Sincerely, Your ___ care team Followup Instructions: ___
19825601-DS-2	19,825,601	26,796,839	DS	2	2168-09-25 00:00:00	2168-10-04 14:30:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / cephalexin Attending: ___. Chief Complaint: Rash Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M PMH significant for a sleep disorder who was seen in ___ on ___ for right elbow cellulitis treated with keflex and bactrim who is being transferred from ___ for as he has developed a rash associated with thrombocytopenia and ___. Pt. called office to report that he was seen in ___ on ___ and being treated for MRSA in right elbow with Keflex and Bactrim. He was then seen again on ___ and he reported great improvement in his symptoms. He reported that there was potentially some drainage at the elbow after treatment with antibiotics, but cannot be certain. On ___, he reported that he started to develop generalized body aches with a fever to 100.7. Then on ___ he noticed that his chest begain to become pruritic and then develop erythema that started in his face. He also believed that he developed worsening facial swelling when he looked in the mirror and particularly believes that his ears were swollen. After the erythema, spread down his arms and his wife noticed it worse on his back and abdomen, sparing the palms. He reported that he subsequently developed worsening fevers to 103.4F that he had been treating with motrin 800mg q6h and acetaminophen at home. When he called his PCP, he was instructed to go to the ___. He denies any new drug exposures other than bactrim. He believes he has taken keflex previously. No recent travel. He does report taking more NSAIDs recently for joint pains, but cannot be certain when it began. He reports + dry mouth. He denies any cough, sore throat, oral ulcers, dry eyes, pain with defecation, dysuria, increasing frequency. He denies any recent travel. In the ___ initial vitals were:100.8 96 102/64 17 98% - ___ Labs were significant for WBC 4.0 (PMNs 76.5, Eos 7.6), Platelets 86. Chem 7 notable for Cr on ___ Cr 1.25). ALt 34, AST 28, Alk phos 51 Tbili 0.43 Albumin 4.3. UA was negative. - Patient was given kerolac. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Sleep Disorder Social History: ___ Family History: Father with DM and kidney CA Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - T:103.2 BP:103/58 HR:115 RR:18 02 sat:96%RA GENERAL: NAD HEENT: AT/NC, EOMI, injected sclera, erythematous facial edema and ear edema. No oral ulcerations NECK: No appreciable lymphadenopathy CARDIAC: tachycardia, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema, No rashes on heels or palms PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: erythematous blanching erythroderma without scaling covering face, back, chest and arms with sparing of the palms Discharge Physical Exam: Vitals- 97.4 79 115/70 18 100% General- Alert, oriented, no acute distress HEENT- Sclera anicteric, moist MMM Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, RUQ tendreness with deep palpation of livers edge, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, no clubbing, cyanosis or edema. Right elbow has decreased edema and erythema. 1cm localized peeling of overlying skin. Non-tender to palpation. No asterixis. Neuro- CNs2-12 intact, motor and sensory grossly normal Skin: improving erythema over chest, face, decreased erythema and petechia over back, scattered erythema over thigh bilaterally. Overall rash seems significantly improved. Pertinent Results: ADMISSION LABS: ___ 08:55PM BLOOD WBC-2.8* RBC-3.90* Hgb-13.3* Hct-36.6* MCV-94 MCH-34.2* MCHC-36.4* RDW-12.8 Plt Ct-71* ___ 08:55PM BLOOD Neuts-72.9* Lymphs-15.8* Monos-2.4 Eos-8.5* Baso-0.3 ___ 09:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 08:55PM BLOOD Plt Smr-VERY LOW Plt Ct-71* ___ 09:20AM BLOOD ___ ___ 08:55PM BLOOD Glucose-113* UreaN-10 Creat-1.2 Na-134 K-4.0 Cl-104 HCO3-23 AnGap-11 ___ 08:55PM BLOOD ALT-48* AST-40 LD(LDH)-207 AlkPhos-54 TotBili-0.5 ___ 08:55PM BLOOD Albumin-3.7 Iron-18* ___ 09:20AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.7 ___ 08:55PM BLOOD calTIBC-213* ___ Ferritn-1161* TRF-164* ___ 09:20AM BLOOD D-Dimer-925* DISCHARGE AND PERTINENT LABS: ___ 08:00AM BLOOD WBC-10.3 RBC-3.97* Hgb-13.4* Hct-38.2* MCV-96 MCH-33.8* MCHC-35.2* RDW-12.8 Plt ___ ___ 08:10AM BLOOD WBC-20.2* RBC-4.31* Hgb-14.4 Hct-40.6 MCV-94 MCH-33.5* MCHC-35.6* RDW-13.6 Plt ___ ___ 07:55AM BLOOD Neuts-52.3 ___ Monos-4.1 Eos-1.5 Baso-0.5 ___ 08:10AM BLOOD ___ PTT-25.7 ___ ___ 09:20AM BLOOD ___ 12:15PM BLOOD ___ 08:00AM BLOOD Parst S-NEGATIVE ___ 08:10AM BLOOD Glucose-92 UreaN-19 Creat-0.7 Na-138 K-4.5 Cl-98 HCO3-31 AnGap-14 ___ 08:00AM BLOOD ALT-1081* AST-581* LD(___)-472* AlkPhos-112 TotBili-0.7 ___ 08:00AM BLOOD ALT-1054* AST-267* LD(___)-289* AlkPhos-109 TotBili-0.8 ___ 08:30AM BLOOD ALT-1084* AST-271* LD(___)-313* AlkPhos-110 TotBili-0.8 ___ 08:15AM BLOOD ALT-886* AST-149* LD(LDH)-273* AlkPhos-108 TotBili-0.6 ___ 08:10AM BLOOD ALT-686* AST-80* LD(LDH)-254* AlkPhos-96 TotBili-0.6 ___ 08:10AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.4 ___ 08:00AM BLOOD calTIBC-260 Ferritn-3619* TRF-200 ___ 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 08:54AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 08:54AM BLOOD ___ ___ 12:15PM BLOOD HIV Ab-NEGATIVE IMAGING: CXR ___ FINDINGS: Compared with ___ and allowing for differences in technique, the cardiomediastinal silhouette is unchanged. Within the limits of plain film radiography, no hilar or mediastinal enlargement and no pulmonary nodules are detected. No CHF, focal infiltrate, or effusion is identified. The minor fissure of the right lung is visible. LIVER/GALLBLADDER U/S ___ IMPRESSION: No acute pulmonary process identified. In particular, no evidence of pneumonia is identified FINDINGS: The liver shows no evidence of focal lesions or textural abnormality. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is normal without evidence of stones or gallbladder wall thickening. The pancreas is unremarkable, without evidence of focal lesions or pancreatic duct dilatation. Evaluation of the pancreatic tail is limited by overlying bowel gas. The spleen is enlarged measuring 14.7 cm and has homogenous echotexture. There is mild fullness of the left renal pelvis. Right and left kidneys are otherwise normal without masses, hydronephrosis or stones. The right kidney measures 11.1 cm and left kidney measures 11.2 cm. The aorta is of normal caliber throughout, without evidence of atherosclerotic plaques. The visualized portions of the inferior vena cava appear normal. DOPPLER COLOR FLOW AND SPECTRAL WAVEFORM ANALYSIS: The main, left and right portal veins, including both anterior and posterior segments, are patent with appropriate directionality of flow. The main hepatic artery presents a normal waveform. The right, middle and left hepatic veins are patent with appropriate directionality of flow. The IVC is within normal limits. The SMV and splenic vein are patent with appropriate directionality of flow. IMPRESSION: 1. Splenomegaly. Otherwise, normal abdominal ultrasound. 2. Patent hepatic veins, portal veins and hepatic artery with appropriate directionality of flow and waveforms. Brief Hospital Course: ___ y/o M PMH significant for a sleep disorder who was seen in ___ on ___ for right elbow cellulitis treated with keflex and bactrim who is being transferred from ___ for as he has developed a thrombocytopenia and ___ concerning for DRESS with elevated liver enzymes improving with steroids. ACUTE ISSUES: # Rash: Patient presented from outside hospital with facial edema with ear edema, along with fevers and eosinophilia that was suggestive of DRESS. It was suspected that it was likely secondary to Bactrim he had taken for the treatment of cellulitis. Dermatology was consulted and suggested high dose steroid therapy with methylprednisolone. Patient was also started on Clobetasol and Fexofenadine for relief of this symptoms. His rash started to improve with the high dose steroid therapy. Doses were increased due to the hepatitis he developed. He was transitioned to PO prednisone and discharged with a 4 week taper and dermatology follow up. HIs rash was significantly improved from admission. He was also started on antibiotic prophylaxis against PCP, ___, calcium supplements and PPI till his steroid dose is completed. # Acute Kidney Injury: Presented to outside hospital with a Cr of 1.42 and started to down trend and was improved on discharge (0.7). Likely thought to be ___ to the drug reaction. #Hepatitis: Patient presented with mild elevation of ALT on admission. During his course these enzymes continued to up trend peaking at ALT of 1084 and AST of 271. Hepatology was consulted and it was thought that this transaminitis was secondary to DRESS. Patient had a RUQ u/s that showed no liver or gallbladder pathology and his viral hepatitis serologies were negative. His methylpred dose was increased and the liver enzymes started to down trend prior to discharge. # Thrombocytopenia + Anemia: Thought to be due to aggressive fluid hydration fork ___ vs drug reaction. Counts started to improve with steroid therapy and returned to baseline at discharge. # R elbow cellulitis: Patient had been treated for cellulitis and completed 7 day course. The affected area continued to heal during hospital stay and he did not require further antibiotic therapy. CHRONIC ISSUES: # Sleep Disorder- patient had a baseline sleep disorder but had increased difficulty sleeping due to high dose steroids he was continued on ativan, wellbutrin, and trazodone. TRANSLATIONAL ISSUES: - Continue steroid taper - Check labs to trend liver enzymes - continue antibiotic prophylaxis against PCP, ___, calcium supplements and PPI till steroid dose is completed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 3 mg PO HS 2. TraZODone 50 mg PO HS:PRN insmonia 3. BuPROPion (Sustained Release) 150 mg PO QAM Discharge Medications: 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. Lorazepam 3 mg PO HS 3. TraZODone 50 mg PO HS:PRN insmonia 4. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone 750 mg/5 mL 10 cc by mouth daily Refills:0 5. Calcium Carbonate 1000 mg PO DAILY 6. Omeprazole 20 mg PO DAILY RX omeprazole 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 7. Vitamin D 800 UNIT PO DAILY RX ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #60 Tablet Refills:1 8. Docusate Sodium 100 mg PO BID 9. Clobetasol Propionate 0.05% Cream 1 Appl TP BID:PRN rash/pruritus Do not use for more than 2 weeks. Do not apply to face, armpits, or groin. RX clobetasol 0.05 % Apply to rash twice a day Refills:0 10. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN pruritus/rash This can be applied to face, armpits, or groin. Use for 2 weeks max, then take 1 week break. RX hydrocortisone 2.5 % Apply to rash on face, armpits, groin twice a day Refills:0 11. PredniSONE 80 mg PO DAILY Take 80 mg daily for 3 more days, then 70 mg daily for 4 more days, then down by 10 mg every 4 days. Tapered dose - DOWN RX prednisone 20 mg ___ tablet(s) by mouth daily Disp #66 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Drug reaction with eosinophilia and systemic symptoms SECONDARY DIAGNOSIS: Acute Kidney Injury Drug induced hepatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. You were hospitalized for a severe drug reaction that caused you to have a rash, swelling, acute kidney injury, and a drop in your blood count. During your hospital stay you also had a hepatitis with elevated liver enzymes. You were diagnosed with DRESS (Drug reaction with eosinophilia and systemic symptoms). It is suspected that this was caused by the antibiotic Bactrim. For this you were treated with high dose steroids. Your symptoms started to improve with the steroids. Please continue to take the steroids as prescribed. You will also be taking an antibiotic to decrease your risk of getting an infection, and calcium and vitamin D supplementation for your bone health. Please follow up with your PCP and dermatologist as described below. You should be sure to have your thyroid function tests checked in 5 weeks time. It was a pleasure taking care of you during your hospitalization. We wish you a speedy recovery. Your ___ Team Followup Instructions: ___
19825620-DS-14	19,825,620	28,225,979	DS	14	2153-04-06 00:00:00	2153-04-07 01:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath with exertion Major Surgical or Invasive Procedure: Exercise stress test History of Present Illness: ___ with past medical history of HTN presents with shortness of breath during strenuous activity. Patient is a firefighter, was taking hose back and forth across ___, became severely short of breath, abnormally so, and then starting going up the stairs in the burning building, and felt lightheaded with presyncopal episode and fell backwards into wall hitting his back. He had been previously in usual state of health without any symptoms (no dyspnea, cough, fevers, leg swelling). He endorses some inhalation of smoke at the fire scene. No history of syncope. +diaphoretic, +nausea. No chest pain. No history of CAD. He states the shortness of breath improved in the ambulance on the way to the ED and has not resumed. Last stress test ___ years ago, per pt he keeps up with this as part of his ___ physical exams. Past Medical History: Hypertension Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission: S: 97.9 156/93 65 18 96%RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple without JVD. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge: VS: T= 97.0 BP= 129/88 HR= 70 RR= 18 O2 sat= 98% RA GENERAL: Middle aged man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple without JVP CARDIAC: RRR, no murmurs appreciated LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: No edema. No femoral bruits. SKIN: Clean, dry intact PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ 2+ DP 2+ ___ 2+ Pertinent Results: Admission Labs: ___ 03:51PM BLOOD WBC-8.9 RBC-4.32* Hgb-12.7* Hct-37.0* MCV-86 MCH-29.3 MCHC-34.2 RDW-13.1 Plt ___ ___ 03:51PM BLOOD Glucose-131* UreaN-16 Creat-1.3* Na-134 K-3.7 Cl-100 HCO3-19* AnGap-19 ___ 10:00PM BLOOD CK(CPK)-1188* ___ 04:55AM BLOOD CK(CPK)-1239* ___ 03:51PM BLOOD cTropnT-<0.01 ___ 10:00PM BLOOD CK-MB-8 cTropnT-0.02* ___ 04:55AM BLOOD CK-MB-9 cTropnT-<0.01 Discharge Labs: ___ 04:55AM BLOOD WBC-8.2 RBC-4.36* Hgb-12.6* Hct-37.8* MCV-87 MCH-28.8 MCHC-33.2 RDW-13.2 Plt ___ ___ 04:55AM BLOOD Glucose-82 UreaN-12 Creat-1.0 Na-138 K-3.9 Cl-104 HCO3-28 AnGap-10 ___ 01:12PM BLOOD CK(CPK)-1096* Exercise Stress: his ___ year old man with h/o HTN and HLD was referred to the lab for evaluation of dyspnea and pre-syncope. The patient exercised for 12 minutes of ___ protocol (~ 12.9 METS), representing a good exercise tolerance. The test was stopped due to fatigue and hypertensive BP response to exercise. No chest, neck, back, or arm discomforts were reported by the patient throughout the study. No reported pre-syncopal type symptoms. In the presence of baseline prominent voltage, there were no significant ST segment changes throughout the study. The rhythm was sinus with rare, isolated APBs and VPBs throughout the study. Baseline systolic hypertension with an exaggerated systolic blood pressure response to exercise. Appropriate heart rate response to exercise. IMPRESSION: No anginal or pre-syncopal type symptoms. No ischemic EKG changes. Baseline systolic hypertension with an exaggerated systolic BP response to exercise. Brief Hospital Course: Active Issues: #Exertional shortness of breath - Given its association with presyncope and exertion, this was concerning for an anginal equivalent. This was especially so in the context of an indeterminate troponin of 0.02. He was risk stratified with exercise stress test without signs of ischemia. He remained free of symptoms during his hospital stay. He was continued on his home lisinopril and aspirin on discharge. #Rhabdomyolysis - His CK was noted to be elevated to 1190 on admission and this value increased lightly on his next set of labs. This was felt most likely from muscle breakdown from his exertion. He was hydrated with 1 liter of NS and his CK was trending down by the time of discharge. He was encouraged to drink fluids. #Acute kidney injury - Creatinine to 1.3 on admission, no baseline in our system. This improved without intervention prior to his ! L of fluid. # Smoke exposure - Stable on room air without complaints of dyspnea. Intermittent cough was improving through hospital stay. Chronic Issues: #GERD - He was continued on his home ranitidine. Transitional Issues: #Exertional symptoms - Would consider ECHO to further characterize function. Stress test done during hospitalization was exercise and EKG only. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Ranitidine 150 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Ranitidine 150 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Shortness of breath with exertion SECONDARY: rhabdomyolysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted after developing shortness of breath with exertion. You had an exercise stress test that did not show any abnormalities. We recommend that you follow up with your doctor for any further testing. We also found that you had some damage to your muscles (rhabdomyolysis), possibly due to the strenous work you were doing prior to admission. We gave you IV fluids for this, with improvement in your blood work. We recommend that you stay well hydrated to limit any further muscle damage. Regards, ___ MDs Followup Instructions: ___
19825840-DS-3	19,825,840	28,322,208	DS	3	2117-04-02 00:00:00	2117-04-05 00:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ with a history of ventricular septal defect s/p closure on ___ and chronic constipation who presents with a weakness, dizziness and a reported pause on her heart monitor. The patient was admitted ___ for planned VSD repair in the setting of worsening right ventricle enlargement and pressures, along with shortness of breath. Her course was notable for an episode of pre-syncope on ___, attributed dehydration from vomiting from severe constipation and reportedly improved with IVF. She notably was found to have a junctional rhythm at that time as well, and was discharged with ___ of Hearts Monitor (___). The patient shares that since discharge, she has continued to feel generally unwell. She says she feels tired and finds that she is short of breath after walking down a hallway (she used the ___ 3 hallway as her example). She does not feel short of breath at rest and has no chest pain. She also has felt generally nauseous. She was also having vomiting, but says her last episode of vomiting was ___. She has chronic constipation, with last bowel movement two days ago. She has also felt warm, but has not taken her temperature. She is unsure if she has had chills. She presented back to the hospital today because her ___ monitor showed a 3.5 second pause and she was instructed to come to the emergency room. In the ED, initial VS were: 99.0 73 140/74 16 100% RA. Labs were notable for normal CBC, chemistries, troponin <0.01 and BNP 118. EKG showed normal sinus rhythm with no notable interval abnormalities. CXR was unrevealing. She was given Tylenol ___ mg, aspirin 243 mg, 1L NS, metoclopramide 10 mg IV, Benadryl 25 mg IV, Zofran 4 mg IV. On arrival to the floor, gives the above history. She adds that she also still has pain around her right groin site where the entry of the procedure was. She says the swelling and bruising has improved, but she still does have some pain. She adds the pre-procedure she felt completely fine. Past Medical History: VSD History of palpitations Hypertension in pregnancy Asthma Migraines Raynaud's Iron deficiency anemia C-section, tubal ligation Carpal tunnel surgery bilaterally ___: abdominoplasty, breast lift/augmentation Drug induced Hepatitis from an herbal weight loss medication Vitamin D deficiency Chronic constipation Polyarthropathy Social History: ___ Family History: Mother: no cardiac Father: no cardiac ___: no cardiac Physical Exam: ADMISSION EXAM: =============== VS: 98.3 129/70 61 16 100 RA GENERAL: sitting up in her chair, appears tired but no acute distress HEENT: anicteric sclera, moist mucosa, no appreciable oral lesions NECK: supple, no LAD, no JVD HEART: RRR, soft systolic murmur heard throughout precordium LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema; right groin setting with no hematoma, no bruit, mild swelling compared to left side and right medial thigh ecchymosis about 5 cm inferior to groin PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: =============== PHYSICAL EXAM: VS: ___ 0734 Temp: 98.6 PO BP: 93/53 HR: 61 RR: 20 O2 sat: 98% O2 delivery: Ra GENERAL: Lying comfortably in bed, NAD. NECK: no JVD HEART: RRR, soft systolic murmur heard throughout precordium LUNGS: comfortably breathing, CTAB ABDOMEN: soft, ntnd, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema; right groin setting with no hematoma, no bruit, mild swelling compared to left side and right medial thigh ecchymosis about 5 cm inferior to groin PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== ___ 03:56PM BLOOD WBC-5.2 RBC-3.72* Hgb-11.2 Hct-34.2 MCV-92 MCH-30.1 MCHC-32.7 RDW-13.2 RDWSD-44.4 Plt ___ ___ 03:56PM BLOOD Neuts-65.4 ___ Monos-5.4 Eos-1.0 Baso-0.4 Im ___ AbsNeut-3.37 AbsLymp-1.41 AbsMono-0.28 AbsEos-0.05 AbsBaso-0.02 ___ 06:30AM BLOOD ___ PTT-29.6 ___ ___ 03:56PM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-141 K-4.7 Cl-102 HCO3-26 AnGap-13 ___ 06:30AM BLOOD LD(LDH)-372* TotBili-0.3 ___ 03:56PM BLOOD Calcium-9.6 Phos-3.8 Mg-1.9 Iron-76 ___ 03:56PM BLOOD calTIBC-269 Ferritn-43 TRF-207 PERTINENT IMAGING: ================== ___ Cardiovascular ECHO Overall left ventricular systolic function is normal (LVEF>55%). There is a ventricular septal defect closure device across the membranous septum with a small residual perimembranous ventricular septal defect with left to right flow. Right ventricular chamber size and free wall motion are normal. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Ventricular septal defect closure device with small residual perimembranous ventricular septal defect with left to right flow. Grossly normal biventricular cavity size and systolic function. Mild mitral regurgitation. DISCHARGE LABS: =============== Brief Hospital Course: Ms. ___ with a history of ventricular septal defect s/p closure on ___ and chronic constipation who presents with a weakness, dizziness and a reported pause on her heart monitor. #Pause #Junctional rhythm: Post-procedure patient was found to go in and out of a junctional rhythm, which per notes was not necessarily associated with when she felt her symptoms. She was given ___ monitor at discharge for closer monitoring, and on the day of presentation she was noted to have a 3.5 second pause. Her telemetry while in the hospital showed sinus bradycardia, but no pauses. The patient's Diltiazem was held on admission. The patient was walking comfortably without any symptoms on the day of discharge and augmenting her heart rate appropriately. Given her improvement of symptoms, her pause was likely secondary to increased vagal tone during sleep with a possible contribution from AV nodal blockade. #Shortness of breath: The patient was admitted with some shortness of breath which resolved during her stay without intervention. The patient had an echo to evaluate her VSD closure device which showed a normal seated and normal functioning device without complications. He shortness of breath could be secondary to some pressure changed post procedurally, but given its quick improvement, no further workup was pursued. #Nausea: The patient had some nausea on the day of admission which resolved. #Constipation: Held PO iron on admission and gave aggressive standing bowel regimen. No clear iron deficiency on lab work so held PO iron given that it was likely exacerbating underlying constipation. Would consider IV iron if patient becomes iron deficient as an outpatient. #S/p VSD repair Aside from junctional rhythm which was noted post operatively, but not while inpatient, patient was well appearing without any evidence of heart failure. Notably still withmurmur, though this is to be expected given the device has not yet had time to endothelialize. Echo showing well seated closure device. Continued Plavix and aspirin daily #Anemia: No clear history of Fe deficiency on chart review with HgB from 11.2 to 9.9 since admission. No iron deficiency on lab work (discussed above.) Some evidence of hemolysis given low haptoglobin which is likely secondary to shearing across new device. CHRONIC/STABLE: =============== #Migraines: Continued home Topamax QHS, sumatriptan if has a migraine #Raynaud's - Continue plaquenil BID - Holding diltiazem as above #Chronic pain #Fibromylagia - Continue gabapentin QHS PRN, ordered as 100 mg (patient takes 100-300 mg PRN) - Home PRN tramadol #Insomnia - Continue home trazodone PRN #Vitamin D 5000 U daily #MVI daily TRANSITIONAL ISSUES: ==================== []Please get CBC at first follow up []PO iron held given constipation and no evidence of Fe deficiency: Would get repeat iron studies with no PO iron repletion to ensure not iron deficiency off of supplementation []If iron deficient, consider IV iron for repletion to avoid constipation []Held patient's Diltiazem on discharge given possible contribution to pauses on telemetry #CODE: Full (presumed) #CONTACT: Father, ___, ___ alternate husband ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 120 mg PO DAILY 2. Docusate Sodium 100 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. Gabapentin 100-300 mg PO QHS 5. Hydroxychloroquine Sulfate 200 mg PO BID 6. Topiramate (Topamax) 100 mg PO QHS 7. Venlafaxine XR 75 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Acetaminophen 650 mg PO Q6H:PRN fever, pain 11. Albuterol Inhaler 2 PUFF IH AS NEEDED shortness of breath 12. Amoxicillin ___ mg PO PREOP dental work 13. diclofenac sodium 4 g topical PRN pain 14. Diclofenac Sodium ___ 75 mg PO DAILY 1 week pre-op 15. Fluticasone Propionate NASAL 1 SPRY NU DAILY 16. Furosemide 20 mg PO DAILY:PRN ankle swelling 17. Multivitamins 1 TAB PO DAILY 18. Sumatriptan Succinate 50 mg PO DAILY PRN headache 19. TraMADol 50 mg PO DAILY: PRN Pain - Moderate 20. TraZODone 50-100 mg PO QHS:PRN sleep aid 21. Vitamin D 5000 UNIT PO DAILY Discharge Medications: 1. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN fever, pain 3. Albuterol Inhaler 2 PUFF IH AS NEEDED shortness of breath 4. Amoxicillin ___ mg PO PREOP dental work 5. Aspirin 81 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Diclofenac Sodium ___ 75 mg PO DAILY 1 week pre-op 8. diclofenac sodium 4 g topical PRN pain 9. Docusate Sodium 100 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Furosemide 20 mg PO DAILY:PRN ankle swelling 12. Gabapentin 100-300 mg PO QHS 13. Hydroxychloroquine Sulfate 200 mg PO BID 14. Multivitamins 1 TAB PO DAILY 15. Sumatriptan Succinate 50 mg PO DAILY PRN headache 16. Topiramate (Topamax) 100 mg PO QHS 17. TraMADol 50 mg PO DAILY: PRN Pain - Moderate 18. TraZODone 50-100 mg PO QHS:PRN sleep aid 19. Venlafaxine XR 75 mg PO DAILY 20. Vitamin D 5000 UNIT PO DAILY 21. HELD- Diltiazem Extended-Release 120 mg PO DAILY This medication was held. Do not restart Diltiazem Extended-Release until you discuss with your cardiologist 22. HELD- Ferrous Sulfate 325 mg PO BID This medication was held. Do not restart Ferrous Sulfate until you discuss with your primary care doctor Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: - Ventricular septal defect - Dyspnea on exertion - Sinus pause - Migraine headache Secondary diagnosis: - Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY WERE YOU ADMITTED? - You were feeling weak and short of breath at home - You were noted to have a short pause on your heart monitor WHAT HAPPENED WHILE YOU WERE HERE? - We monitored your heart on telemetry and there were no concerning findings - You had an ultrasound of your heart which showed a normally functioning ventricular septum defect closure device - You continued to have some shortness of breath with exertion, so you had a stress test - This stress test showed decreased blood pressure during exercise, indicating that you may have trouble increasing your heart rate with exercise. WHAT SHOULD I DO WHEN I LEAVE? - Please take all of your medications as prescribed and follow up with all of your doctors as arranged for you - You will have further testing for fainting as an outpatient - Please continue wearing and transmitting your holter (cardiac) monitor. It was a pleasure to care for you during your stay. -Your ___ team Followup Instructions: ___
19826220-DS-15	19,826,220	26,609,430	DS	15	2134-12-26 00:00:00	2135-01-23 21:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Brevital / morphine / Penicillins Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ with asthma and pulmonary sarcoid on chronic steroids (recent progression off steroids), PNA recently treated in ___, and reactive airways disease presenting with worsening shortness of breath and cough. She noted that her breathing became worse 2 days prior to admission but she noted improvement using albuterol nebs at home. This was accompanied by a mild non-productive cough. However, over the past day she had significant worsening of her cough, which was still non-productive. She denies any fevers, chills, sick contacts, or recent travel. She reported to the ED and upon arrival she was tachycardic in the 150s with saturations >98% on room air. She was given back to back duonebs, IV mag, IV solumedrol, 2L IVF. Her initial CXR was concerning for PNA and she was started on CTX/Azithro. She was not particularly wheezy and a D-Dimer was >500 so she underwent CTA chest which was a limited study due to motion but showed no motion artifacts down to the segmental level. There was a right hilar infiltrate initially read as potentially concerning for PNA. Given her significant tachcyardica and tachypnea she was admitted to the ICU. Review of systems: (+) Per HPI Past Medical History: Sarcoidosis, followed by Dr. ___ airways disease Pre-diabetes Social History: ___ Family History: Father - ___ Mother - ___, glaucoma Sister- RA, asthma Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- T: 98.1 BP: 107/77 P: 143 R: 36 O2: 98% 2LNC GENERAL: Alert, oriented, moderately increased work of breathing HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated LUNGS: Decreased air movement at the bases, scattered wheezes throughout CV: Tachycardic, regular ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No rashes or lesions. Multiple tattoos. NEURO: AAOx3, moves all extremities antigravity to command DISCHARGE PHYSICAL EXAM: AVSS Gen: NAD, alert and oriented CV: rrr, no r/m/g Lungs: good air movement, no wheeze or rales Abd: soft, nontender, nondistended Ext: no edema Neuro: alert and oriented x 3 Pertinent Results: ADMISSION LABS: ___ 01:50AM BLOOD WBC-10.4 RBC-4.89 Hgb-12.9 Hct-40.8 MCV-84 MCH-26.3* MCHC-31.5 RDW-15.0 Plt ___ ___ 01:50AM BLOOD Neuts-66.4 ___ Monos-7.8 Eos-1.6 Baso-0.4 ___ 01:50AM BLOOD Plt ___ ___ 01:50AM BLOOD Glucose-139* UreaN-13 Creat-1.0 Na-137 K-3.5 Cl-100 HCO3-18* AnGap-23* ___ 01:50AM BLOOD D-Dimer-686* STUDIES/IMAGING: CTA Chest ___: CTA Chest:The examination is partially limited by respiratory motion. The thoracic aorta is normal in caliber without dissection or intramural hematoma. The aortic arch vessels are normal appearing. The pulmonary artery enhances without filling defect centrally. There is no evidence of filling defects in the lobar or segmental pulmonary arteries. CHEST: There are numerous enlarged mediastinal, prevascular, paratracheal, and hilar lymph nodes in keeping with sarcoidosis. Lymphoid tissue has increased over time since the prior CTA, particularly in the left perihilar region. This results in attenuation of the ___ order airways of the right upper lobe, which are normal in caliber peripherally. The esophagus follows a normal course and is normal in caliber. Heart is normal in size with no pericardial effusion. Limited views of the upper abdomen demonstrate hypodensities in the liver which are incompletely characterized. The lungs demonstrate heterogeneous micronodules in a bronchovascular distribution in the right upper and lower lobe. Scattered micronodules are new in the lingula and left lower lobe. Irregular solid nodule at the right lung apex (2:2) measures 14 x 12 mm, appearing slightly different in morphology from ___. There is no pleural effusion or pneumothorax. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. Worsening sarcoid. Liver hypodensities, not able to characterize, IMPRESSION: 1. Limited examination secondary to respiratory motion, however no evidence of central, lobar, or segmental pulmonary embolism. 2. Diffuse micronodules in a bronchovascular distribution, worsened since the prior CTA of the chest, compatible with worsening of known sarcoidosis. 3. Significant increase in perihilar lymphoid tissue, with compression on the ___ order airways of the right upper lobe. CXR ___: FINDINGS: There is again bilateral hilar enlargement, compatible with lymphadenopathy, which has worsened since the prior radiograph, more so in the right. Increasing micronodular opacities in the right upper and lower lung may represent worsening sarcoid, less likely superimposed pneumonia. Elevation of the right hemidiaphragm is unchanged. No large pleural effusion or pneumothorax. Heart size is normal. IMPRESSION: 1.Increased right perihilar micronodules may represent worsening sarcoid, however infection is also a possibility. 2. Increased bilateral hilar prominence consistent with lymphadenopathy. PFTs ___ FVC 2.66L (86%) FEV1 1.96 (75%) FEV1/FVC 74% Mild obstructive defect. ___ 07:15AM BLOOD WBC-10.7 RBC-4.35 Hgb-11.8* Hct-36.0 MCV-83 MCH-27.1 MCHC-32.8 RDW-15.0 Plt ___ ___ 07:15AM BLOOD Glucose-84 UreaN-18 Creat-0.9 Na-138 K-3.5 Cl-103 HCO3-24 AnGap-15 ___ 01:50AM BLOOD HCG-<5 ___ 07:30AM BLOOD HCV Ab-PND Brief Hospital Course: ___ w/asthma and sarcoidosis presenting with shortness of breath and cough that was abrupt in onset with CT evidence of a confluent opacity in the R mid-lung zone in addition to micro-nodular pulmonary opacities and lymphadenopathy. #Community acquired pneumonia: Resolved. Completed ceftriaxone/azithro. Review of imaging with radiology made it clear that it likely was not pneumonia but rather progression of sarcoidosis that lead to CT changes/infiltrate. She never had fever or leukocytosis. #Sarcoidosis w ongoing dyspnea, acute on chronic disease. Her pulmonologist, Dr. ___ patient in hospital and review of chest imaging with radiology lead to diagnosis that her symptoms were due to progression of sarcoidosis. Pulmonary did not feel that she required referral to IP for bronchoscopy and lung biopsy at this time. She was started on prednisone 60mg during admission. This did not cause resolution of symptoms and with input from pulmonary and agreement from patient after reviewing all the nature of treatment. She was started methotrexate 5mg q week (on ___ (q ___ (expect no immediate improvement in her symptoms with this therapy) Negative urine hcg and she was counseled on contraception and use of folate supplementation. --dose of methotrexate will be increased gradually as an outpatient by pulmonary --viral hepatitis serologies negative --Left forearm planted PPD ___ and read on ___ induration 0mm erythema --atovaquone for PCP ppx and use of folate supplements --will remain on prednisone 60mg daily without plan to initiate taper for a period of weeks/months with close pulmonary f/u who will determine when to begin taper - Dr. ___ and she was given outpatient referral for pulmonary rehab #Sinus Tachycardia: ___ dehydration, albuterol and respiratory distress. -- Per prior notes "her pulmonologist reported that her sinus tachycardia is a known issue and previously assessed for any structural heart disease leading to this with cardiac MRI. he had planned to refer patient to EP in the past --repeat TTE ___ does not suggest structural heart disease but suboptimal images" PRE-DIABETES: did not require insulin despite use of steroids Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea/wheeze 3. PredniSONE 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: exacerbation/progression of pulmonary sarcoidosis sinus tachycardia bacterial pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You were evaluated for new severe cough and shortness of breath. You received antibiotics to treat pneumonia. We believe the real cause of your shortness of breath is progression of your pulmonary sarcoidosis. To treat the sarcoidiosis you have been started on high dose steroids. Steroids have numerous side effects such as causing elevated sugars, poor sleep, osteoperosis risk, infections, such as PCP ___. You are on medicine mepron to reduce risk of acquiring PCP ___. The steroids should NOT be stopped abruptly or without guidance by your doctors. At ___ future date the steroid dose will be gradually lowered. You also started methotrexate to help treat the sarcoidosis, this medicine can effect your immune system. Please let all medical providers you take this medication. the dose may be changed by your pulmonologist. Because it can affect your liver, please do not drink alcohol until you have had a discussion with your pulmonologist. You have been provided with a prescription to undergo pulmonary rehab. Please contact the rehab clinics in your area to arrange an appointment. Take care, ___, MD Followup Instructions: ___
19826364-DS-20	19,826,364	24,850,130	DS	20	2170-01-02 00:00:00	2170-01-04 10:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: vaginal bleeding Major Surgical or Invasive Procedure: dilation & curettage (D&C) History of Present Illness: ___ ___ presented from PCP office with vaginal bleeding, hypotension and rash. Had Med Ab at ___ on ___ at 8wk gestation after which she reported heavy bleeding and cramping, changing ___ pad every 1 hour for several hours. She had a follow-up HCG several days after her Med Ab with an appropriate drop in HCG per her report. Since then she reports continued intermittent vaginal bleeding and menstrual-like cramping. She was seen at ___ Parent___ last week at which time she was started on OCPs for continued bleeding, no ultrasound was performed at that time. She continued to have bleeding and cramping throughout the week and yesterday began having chills, malaise and nausea/vomiting. She woke up today with a diffuse erythematous, non pruritic rash. This coupled with her other symptoms prompted her to present to her PCPs office for evaluation. On arrival there she was noted to be tachycardic to the 140s and hypotensive ___ so was transferred to ___ ED for urgent evaluation. On arrival to the ED she was triggered for tachycardia in the 130s but was normotensive and was started on fluid resuscitation. She reported chills and malaise but her nausea and rash had improved. She reported that she continued to have vaginal bleeding but only had to change a pad every few hours and it was not saturated. She also reported suprapubic abdominal discomfort and cramping. She denied emesis and last ate at 3:30pm She denied CP, SOB, dysuria, urinary frequency, abnormal vaginal discharge. Past Medical History: OBGYNHx: ___ - SAB x 1, spontaneous - TAB x 2, ___ and ___, both med Ab - Irregular menses every ___ days lasting ___ days, heavy with mild to moderate dysmenorrhea - Denies any history of STIs, cysts, fibroids - Contraception: OCPs PMH: depression (previously on medication, currently sees ___) PSH: denies Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: ======================================== Labs ======================================== ___ 07:10PM BLOOD WBC-10.8* RBC-3.37* Hgb-11.1* Hct-32.6* MCV-97 MCH-32.9* MCHC-34.0 RDW-13.0 RDWSD-46.1 Plt ___ ___ 07:10PM BLOOD ___ PTT-28.7 ___ ___ 07:10PM BLOOD Glucose-87 UreaN-12 Creat-0.6 Na-144 K-3.0* Cl-112* HCO3-20* AnGap-15 ___ 07:10PM BLOOD HCG-410 ___ 07:17PM BLOOD Lactate-2.5* ___ 02:54AM URINE Color-Straw Appear-Clear Sp ___ ___ 02:54AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 02:54AM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE Epi-2 ___ 02:54AM URINE CastHy-3* ======================================== Microbiology ======================================== ___ 2:54 am URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 7:21 pm SWAB Site: CERVIX Source: Cervical. FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by PANTHER System, APTIMA COMBO 2 Assay. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by PANTHER System, APTIMA COMBO 2 Assay. ======================================== Imaging ======================================== Pelvic ultrasound ___ FINDINGS: The uterus is anteverted and measures 8.5 x 4.6 x 6.9 cm. The endometrium is heterogenous with a 1.4 x 1.8 x 2.9 cm hypoechoic region with internal vascularity, consistent with vascularized retained products of conception. The ovaries are normal. Due to acute, localized pain symptoms, spectral and color Doppler of the ovaries was performed. There was normal arterial and venous flow demonstrated within the ovaries. There is no free fluid. IMPRESSION: 1.4 x 1.8 x 2.9 cm area of vascularized retained products of conception. Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service for vaginal bleeding. Prior workup in the emergency department was concerning for endometirits given tachycardic, hypotensive and new onset rash. Pelvic ultrasound showed retained products of conception and she underwent a dilation and curettage. Please see the operative report for full details. Given the concern for endometritis, she received IV gentamicin and clindamycin for 24 hours. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with oral Tylenol and ibuprofen. She was transitioned to oral doxycycline and flagyl for a planned 10 day course. She was continued on her home oral contraceptives for contraception. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: 1. ___ (___) (levonorgestrel-ethinyl estrad) 0.15-0.03 mg oral DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not take more than 4000 mg in 24 hours RX acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #30 Tablet Refills:0 2. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice per day Disp #20 Tablet Refills:0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate Please take with food RX ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #30 Tablet Refills:0 4. MetroNIDAZOLE 500 mg PO BID RX metronidazole 500 mg 1 tablet(s) by mouth twice per day Disp #20 Tablet Refills:0 5. Altavera (28) (levonorgestrel-ethinyl estrad) 0.15-0.03 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: retained productsw of conception endometritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. Please continue to take your antibiotics as instructed for the next ___ days. General instructions: Take your medications as prescribed. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks. * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
19826426-DS-10	19,826,426	28,343,885	DS	10	2149-12-23 00:00:00	2149-12-26 21:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I've been feeling more depressed" Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is an unmarried retired ___ yr old Caucasian woman with history of depression who self-presents to ___ ED for evaluation for admission for inpatient ECT. She was doing very well psychiatrically since her last course of outpatient maintenance ECT at the ___, possibly as long as ___ yrs ago. She had been active and without any major depressive or anxious symptoms until ~2 weeks ago. At that time she started feeling more low mood and severe anxiety with inability to fall asleep at night. While she had been seeing her outpatient psychiatrist every ___ successfully, she started calling the clinic much more often due to various concerns. She tried a number of medications including very-low-dose fluoxetine and quetiapine for outpt treatment though each one appeared to cause significant side effects and so had to be stopped after just a few days. Currently she says she wants to "take the bull by the horns" and do whatever it takes to put a stop to this episode as soon as possible, including admission and possibly ECT trial. Recently seen in BI ED by psychiatry on ___ for depression and irritability; she was not interested in higher level acute treatment at that time and was discharged home to outpt followup. On Psych ROS she endorses depressive symptoms as above but has maintained fairly good interests, energy, and motivation. Some ambivalence about SI - says that "this time it might have come to that" but can't think of anything she would have actually done. No manic sxs reported. No hallucinations or delusions reported. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: Handful in remote past, reportedly at ___, for depressive episodes Current treaters and treatment: Sees Dr. ___ for outpatient psychiatri Medication and ECT trials: failed recent trials of Prozac, Seroquel; success with ECT in past Self-injury: denies hx Harm to others: denies Access to weapons: none PAST MEDICAL HISTORY: Hypertension Pernicious anemia Right foot pain History of colitis Peripheral neuropathy History of CAP Pneumonia (___) Hiatal Hernia History of hysterectomy Social History: SUBSTANCE ABUSE HISTORY: EtOH: 2 glasses wine/night (1 bottle/2 days) every night. ___ have had a problem with alcohol in the past when she would drink 4 glasses of wine a night, however, denies withdrawal including withdrawal seizures. Tobacco: Denies. Illicits: Denies. FORENSIC HISTORY: ___ SOCIAL HISTORY: ___ Family History: none known Physical Exam: Physical Examination: VS: 99.2, 69, 178/84, 16, 98%RA, 5'8", 169 lbs General- NAD Skin- no rashes or bruises, moles on left should, back and chin HEENT- PERRLA, MMM, normal oropharynx Lungs- CTA bilaterally CV- RRR, N S1 and S2, no m/r/g Abdomen- Soft, NT, ND, +BS, no guarding or rebounding Extremities- No edema, normal tone Neuro- CN II-XII intact, gait slow and wide based with aid of cain, Romberg negative, FTF intact, Heel to shin intact, ___ strength UE & ___ bilaterally, normal sensation throughout Neuropsychiatric Examination: Appearance: Caucasian female appearing stated age, in gown, good grooming, sitting in chair with cane across lap, smiling Behavior: Cooperative, appropriate, good eye contact Mood and Affect: "Not good," Euthymic, not congruent with mood Thought process: Linear, goal oriented Thought Content: No SI, HI, AH, VH. Wants ECT treatment. Judgment and Insight: Fair/fair Cognition: Attention: +MOYB Orientation: ___ Memory: ___ registration, ___ after 5 mins, ___ with prompting Fund of knowledge: Able to name first and current ___, able to name play by ___ and ___ Calculations: 7q= 0.65 or 0.70 Don't judge a book by its cover: "People aren't always the same" Apple/orange: Fruit Speech: Normal rate, tone and volume Language: Fluent Pertinent Results: ___ 02:35PM BLOOD WBC-7.5 RBC-3.92 Hgb-12.0 Hct-37.7 MCV-96 MCH-30.6 MCHC-31.8 RDW-12.4 Plt ___ ___ 02:35PM BLOOD Neuts-46.7* Lymphs-42.7* Monos-6.6 Eos-3.3 Baso-0.7 ___ 02:35PM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-137 K-4.1 Cl-101 HCO3-27 AnGap-13 ___ 02:35PM BLOOD ALT-16 AST-17 AlkPhos-47 TotBili-0.3 ___ 02:35PM BLOOD VitB12-GREATER TH Folate-16.0 ___ 02:35PM BLOOD TSH-1.9 ___ 02:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:37PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 05:37PM URINE RBC-1 WBC-16* Bacteri-FEW Yeast-NONE Epi-3 TransE-<1 ___ 05:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: #) Neuropsychiatric: At the time of admission Ms ___ mental status was characterized by both depressive and notable persistent anxious features, as well as deficits in her cognitive status including with executive function, calculation, and short-term memory. MOCA taken at initial eval scored ___ with most deficits in those areas but intact orientation, long-term memory, and language. It was unknown how her status at that time compared to her baseline exactly though we felt it likely that it had been acutely but reversibly lowered by depression and anxiety as well as medication effects (amitriptyline) and possible UTI. The TCA was held at admission to alleviate possible adverse effects on cognition and the UTI was treated with a full course of PO Macrobid in-house (see below for further details). With regard to the depression and anxiety, inpatient ECT had been considered for this largely med-intolerant patient. Upon review she clearly had a number of medical as well as social risk factors for above-average difficulty with the procedure including heart disease, likely underlying cognitive problems, advanced age, vertebral and chest wall defects on CXR, limited ability to adhere to outpatient treatment plans, and limited support in the community for continuing such an invasive procedure as an outpatient. She herself was also hesitant to consider it except as a last resort. She also was unwilling to remain in the hospital for an ECT course. She had undergone a number of psychopharm med trials in recent months but had complained of intolerability of all of them and received no benefit. Shortly after admission she was trialed on Remeron at 15 mg HS for aid with sleep, appetite, and anxiety as well as low mood itself. She complained that it caused her stomachaches and anxiety and was resistant to the idea that these symptoms were unlikely caused by the med itself. The mirtazepine's benefit for her sleep was mixed as she continued to experience fragmented sleep cycles at night, and it was discontinued after several days. It was replaced with Seroquel at 25mg HS which likewise led to still mixed sleep quality at night and vague complaints of thumping in her chest, perhaps palpitations. It was likewise discontinued after 2 doses. Sertraline was then started at 25 mg daily; she tolerated the first 2 doses without any particular effects and it was continued through discharge. It was felt that an SSRI at a small dose, that could be increased as indicated through time would be the safest and potentially best tolerated medication through time. At the time of discharge her levels of reported depression and anxiety were mildly improved from admission. The low-level SI (without intent or plan) she had endorsed at admission and early in the course was no longer present. Her cognition was grossly similar as well, with perseveration on similar issues such as getting back to certain elements of her routine and her worries about certain medication effects. MMSE close to the end of her course revealed score of ___, again with deficits in the areas above. #) Medical: UTI- Ms ___ had been thought to have a UTI at a prior ED visit and was started on empiric abx though did not complete the course. Repeat U/A at this eval was again suggestive of infection and as she may have been suffering cognitive impact from the process we complete an empiric course of Macrobid while in-house. Colitis- Throughout her hospital course Ms ___ was complaining of constipation rather than loose stool. Amitriptyline was initially held as above both for neurologic reasons and the constipating effects. At the PCP's recommendation we also discontinued Budesonide as she was not having any active colitis symptoms. PRNs of Senna and Colace with occasional Milk of Mag were used with good effect in relieving constipation. HTN- At admission Ms ___ was continued on her home atenolol and lisinopril. The pt's BP fluctuated during her course, generally elevated in the SBP 130-170 range and asymptomatic. No acute interventions for this were performed during this hospitalization. Pernicious anemia- At initial testing Ms ___ and serum folate/B12 levels were actually WNL. She was continued on her home PO cyanocobalamin and additionally received an IM injection of 1000 mcg B12 as she stated she was scheduled to do monthly. #) Legal: ___ #) Psychosocial: Given the limited ability to manage her neuropsychiatric symptoms pharmacologically we attempted to muster social support for in the community as much as possible. Her niece ___ and ___ were kept in frequent communication and informed of the need, in the short term, to escalate the level of observation and assistance Ms ___ receives in order to prevent rehospitalizations; they were amenable to involvement in this way ongoing. The ___ RN care manager ___ ___ was also involved as a point of contact and for treatment planning at this time and to continue after discharge; this had been attempted previously but with limited impact. Ms ___ expressed greater interest this time and arranged to meet Ms ___ first in the unit and then later in her home after discharge to arrange services as required. #) Risk assessment: Ms ___ runs a number of static/chronic risk factors for poor outcome psychiatrically, including mixed neurologic co-morbidity, numerous chronic medical illnesses, limited ability demonstrated to cooperate with outpatient treatment attempts, and limited flexibility in managing her daily structure. Acute risk factors which have been addressed and ameliorated as possible include limited social supports and transient passive suicidality. Protective factors include future orientation to her activities of enjoyment, well-demonstrated help-seeking behavior when needed, and lack of history of injurious behavior towards self or others. She did not present as an acute risk to herself at time of discharge, and the need for family support and increased services at home was emphasized with both the patient and her family. Increased strucutre and support will be her most important modifiable factor through time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Budesonide 3 mg PO DAILY 4. Cyanocobalamin 100 mcg PO BID 5. Amitriptyline 25 mg PO HS Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Cyanocobalamin 100 mcg PO BID 3. Lisinopril 20 mg PO DAILY 4. Sertraline 25 mg PO DAILY RX sertraline 25 mg 1 tablet(s) by mouth once a day Disp #15 Tablet Refills:0 5. Senna 1 TAB PO BID:PRN constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #30 Tablet Refills:0 6. Docusate Sodium 100 mg PO BID constipation RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:*0 7. Cyanocobalamin 1000 mcg IM/SC ONCE Duration: 1 Doses Last received ___. Please continue to discuss its ongoing need with Dr. ___ ___ Disposition: Home Discharge Diagnosis: Axis I: Major Depression, recurrent; Cognitive disorder NOS - Most likely Mild Dementia (scores ___ on MMSE and ___ on MOCA - observed short term memory deficits in the hospital appear to be the most disabling) Axis II: deferred Axis III: HTN, pernicious anemia, neuropathy, hiatal hernia, UTI (treated), colitis. Significant constipation Discharge Condition: Appearance: elderly Caucasian woman appears around stated age wearing hospital gown and scrub pants, hair remains disheveled but cleaner Gait/tone: posture is kyphotic, gait is quite slow with short steps but generally stable with use of cane; tone appears grossly normal Behavior: calm, cooperative, sits upright at table for breakfast, good EC, no particular PMR/PMA, no adventitious mvmts Speech: grossly normal rate/tone/prosody, no slurring/dysarthria Mood: 'not good' Affect: still fairly anxious with hints of irritability but generally euthymic, good range, mood- and content-congruent Thought Process: remains perseverative on a number of same issues as in other interviews this week, e.g. the AEs of meds, her preference for her own routine, contact with her outpt MDs; some tangentiality in narrative, rather easily redirectible to topic Thought Content: no prominent delusions/paranoia; Perceptions: denies Auditory/Visual/Somatic hallucinations; not appearing to respond to internal stim Suicidality/Homicidality: Denies SI; does not endorse HI Insight/Judgment: some understanding of nature of illness and need for tx though difficulty engaging in tx planning in short or long term, and limited insight of impact of caffeine/etoh use Cognitive Exam: alert and awake, appears grossly unchanged from last week Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you felt unstable, depressed, and anxious. You improved while in the hospital. It has been a pleasure taking care of you. We wish you good luck in your recovery! -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. Recall we talked about limiting wine to 1 small glass per day, and reducing coffee or other caffeine intake. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. Followup Instructions: ___
19826426-DS-11	19,826,426	29,627,457	DS	11	2150-02-11 00:00:00	2150-02-11 13:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with h/o depression, lymphocytic colitis, and hypertension presents from clinic via ED with cough and fever x ___ days. Reports nonproductive cough, subjective fevers, and chronic diarrhea (6 BM per day from lymphocytic colitis on Etrafon but not adherent with Entocort), but denies chills, dyspnea, chest pain, cramping, nausea, vomiting, abdominal pain, or dysuria. Had temp 99.6 but satting 94% RA in PCP office with left basilar rales and loose nonproductive cough, and was sent to ED for evaluation of pneumonia given patient's frailty and marginal competency. In the ED, initial vital signs were 98.4 70 147/64 18 96% RA. Labs wnl (normal WBC and lactate), except K 3.0, for which she received 40mg KCl. CXR showed increased LLL opacity. Patient was given levofloxacin 750mg IV. Transfer vitals were 100.4 84 98 20 98% On the floor, patient reports being comfortable though still with continued cough and occasional diarrhea. Past Medical History: Hypertension Pernicious anemia Right foot pain History of colitis Peripheral neuropathy History of CAP Pneumonia (___) Hiatal Hernia History of hysterectomy Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 99.7, 171/80, 76, 16, 97% RA General: NAD, pleasant HEENT: NCAT, dry MM Neck: supple CV: regular rhythm, no m/r/g Lungs: decreased coarse breath sounds in LLL but otherwise clear, no w/r/r Abdomen: soft, NT/ND, BS+ Ext: WWP, no c/c/e Neuro: moves all extremities grossly DISCHARGE PHYSICAL EXAM: Vitals: 97.9 113/70 66 16 100% RA General: NAD, pleasant HEENT: NCAT, dry MM Neck: supple CV: regular rhythm, no m/r/g Lungs: Rhonchi heard midway up R lung and also at LLL base Abdomen: soft, NT/ND, BS+ Ext: WWP, no c/c/e Neuro: Moves all extremities grossly SKIN: numerous nevi over whole body Pertinent Results: ADMISSION LABS: ___ 01:00PM BLOOD WBC-5.2 RBC-3.76* Hgb-11.8* Hct-35.1* MCV-93 MCH-31.3 MCHC-33.5 RDW-12.5 Plt ___ ___ 01:00PM BLOOD Neuts-56.1 ___ Monos-10.9 Eos-0.6 Baso-0.5 ___ 01:00PM BLOOD Glucose-94 UreaN-13 Creat-0.8 Na-140 K-3.0* Cl-103 HCO3-27 AnGap-13 ___ 01:12PM BLOOD Lactate-0.8 DISCHARGE LABS: ___ 07:50AM BLOOD WBC-5.4 RBC-3.51* Hgb-10.8* Hct-32.5* MCV-93 MCH-30.9 MCHC-33.3 RDW-12.7 Plt ___ ___ 07:50AM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-141 K-3.3 Cl-107 HCO3-24 AnGap-13 ___ 07:50AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9 MICRO: Blood cultures x2- pending C.Diff- negative IMAGING: CXR ___: Ill-defined opacity in the posterior left lower lobe, could represent pneumonia in the appropriate clinical setting. CXR ___ IMPRESSION: Bilateral lower lobe volume loss/infiltrates. Brief Hospital Course: Impression: ___ h/o depression, lymphocytic colitis, and hypertension who presented from clinic via ED with cough and fever x ___ days, found to have likely LLL PNA. Additionally, her persistent diarrhea due to lymphocytic colitis was also an ongoing active issue # PNA: Patient was diagnosed with community-acquired pneumonia given the infiltrate seen on CXR and productive cough. She was treated with IV levofloxacin initially as she was having diarrhea related to her lyphocytic colitis (concern for absorption) and was transitioned to PO levofloxacin once her diarrheal symptoms improved. She will complete a 7 day course. Her cough was treated symptomatically with guaifenesin-D, tessalon perles, and cough drops. #Lymphocytic colitis: C.Diff was sent off to ensure no active ongoing infection which was negative. Patient was started on loperamide which drastically helped her diarrhea, and was scheduled for every 3 hours as needed. #Disposition: Patient was seen by ___ who recommended home ___, however patient preferred to go to rehab and was successfully screened by our case management services. She will be discharged to ___ of ___ # Hypertension: continued on atenolol # Depression: continued on sertraline # Red eye: started erythromycin ointment x 5 days (___). TRANSITIONAL ISSUES: -Anticipated length of stay <30 days at rehab -Pt needs ongoing discussion with PCP regarding lymphocytic colitis and further treatment options. She was told to consider starting culturelle as an adjunctive measure in the meantime. -Pt will complete 7 day course of levofloxacin for community acquired pneumonia # Code: Full # Emergency Contact: nephew/HCP ___ ___, cell ___ # Will need follow-up CXR in ___ weeks after ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY hold for SBP<95, HR<55 2. Sertraline 25 mg PO DAILY 3. Cyanocobalamin 1000 mcg IM/SC MONTHLY Discharge Medications: 1. Atenolol 50 mg PO DAILY 2. Sertraline 50 mg PO DAILY 3. LOPERamide 2 mg PO Q3H:PRN diarrhea 4. Cyanocobalamin 1000 mcg IM/SC MONTHLY 5. Levofloxacin 750 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: bacterial pneumonia lymphocytic colitis SECONDARY: hypertension depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure participating in your care at ___. You were admitted for pneumonia. You were treated with levofloxacin pills (antibiotics). We also gave you immodium to help decrease the amount of diarrhea that you were having. Please take the immodium every 3 hours as needed for diarrhea. You can also consider starting culturelle to help regulate your bowel movements. Please take your antibiotic (levofloxacin) for one more day, ending after your dose on ___. Please follow up with your PCP. Followup Instructions: ___
19826426-DS-12	19,826,426	27,541,174	DS	12	2153-09-26 00:00:00	2153-09-28 05:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: S/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with history of neurocognitive disorder, heart failure, lymphocytic colitis, hypertension and peripheral neuropathy presenting from assisted living (___) with unwitnessed fall at 10pm tonight. She has difficulty recalling the event, but reports a mechanical fall. Denies chest pain, dyspnea, palpitations prior to fall. She denies headache or vision change. Denies loss of consciousness. No cough, no fevers or chills, no O2 at home. Reports history of shortness of breath. Reports soreness in the legs and occaisional swelling in legs. No nausea, vomiting, diarrhea, abdominal pain, dysuria. Per nephew, last saw patient over ___, patient had declined since prior visit in ___. Patient with difficulty moving and with transfers. Also, refused to go to the bathroom and insisted on going in diapers. At baseline, is able to eat and walk with walker. In the ED, initial VS were 98.6 76 151/61 18 95-100% RA. Workup notable for leukocytosis with neutrophil predominance, vascular congestion on CXR, ___. Given vancomycin, ceftriaxone and azithromycin in the emergency department. Recieved tetanus shot. Cultures drawn prior to antibioitcs. Decision was made to admit to medicine for further management. Past Medical History: Hypertension Pernicious anemia Right foot pain History of colitis Peripheral neuropathy History of CAP Pneumonia (___) Hiatal Hernia History of hysterectomy Heart failure Social History: ___ Family History: Unknown. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.8 147 / 83 91 16 92 2LNC GENERAL: AAOx2.5, unable to say days of week backwards. Tired appearing, not wanting to participate fully in exam. HEENT: Multiple hyperpigmented coin-shaped stuck-on lesions over face NECK: JVP elevated HEART: RRR, II/VI systolic murmur at base, I/VI diastolic murmur at apex. LUNGS: No accessory msucle use, decreased lung sounds at bases bilaterally, mild crackles. ABDOMEN: NTND EXTREMITIES: bilateral pitting edema to knees, lower extremities tender with overlying scale. 2 cm laceration/skin tear over R ___ index finger PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: 97.8 136/71 83 18 90 RA I/O: NR, pt incontinent. GENERAL: Alert, resting comfortably in chair HEENT: Multiple hyperpigmented coin-shaped stuck-on lesions over face NECK: JVP assessment limited by patient positioning. Not visible at 90 degrees. HEART: RRR, II/VI systolic murmur at base, I/VI diastolic murmur at apex. LUNGS: No accessory msucle use, decreased lung sounds at bases bilaterally, bibasilar crackles. ABDOMEN: NTND EXTREMITIES: lower extremity edema resolved. Continues to have tenderness of the lower shins, with evidence f stasis dermatitis on the skin. KNEE: Left knee is not swollen or erythematous. Chronic abnormalities from prior surgery. No tenderness at the time of exam. PULSES: 2+ DP pulses bilaterally NEURO: No gross motor/coordination abnormalities. SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: =========================== ADMISSION/IMPORTANT LABS: =========================== ___ 01:10AM BLOOD WBC-16.4# RBC-4.05 Hgb-11.8 Hct-38.0 MCV-94 MCH-29.1 MCHC-31.1 RDW-13.0 RDWSD-44.8 Plt ___ ___ 01:10AM BLOOD Neuts-74.1* Lymphs-16.9* Monos-7.0 Eos-1.0 Baso-0.3 Im ___ AbsNeut-12.14* AbsLymp-2.77 AbsMono-1.14* AbsEos-0.17 AbsBaso-0.05 ___ 01:10AM BLOOD Glucose-92 UreaN-35* Creat-1.8* Na-134 K-6.4* Cl-97 HCO3-21* AnGap-22* ___ 01:10AM BLOOD proBNP-361 ___ 08:25AM BLOOD CK-MB-3 cTropnT-0.03* ___ 07:05PM BLOOD Calcium-8.4 Phos-4.2 Mg-1.9 ___ 01:10AM BLOOD K-5.3* ___ 02:50PM BLOOD K-4.6 ============================ MICROBIOLOGY: ============================ ___ 1:10 am BLOOD CULTURE: PENDING ___ 8:50 am URINE CULTURE: (Final ___: NO GROWTH. ============================ STUDIES/IMAGING ============================ CXR ___: 1. Mild pulmonary vascular congestion, bibasilar atelectasis, and suspected small bilateral effusions. 2. No evidence of pneumothorax. 3. Old healed posterior left rib fractures. Within the limitations of chest radiography, no new rib fracture detected. CT HEAD ___: -No evidence of acute intracranial hemorrhage. FINGER(2) 2+ VIEWS RIGHT: No evidence of right index finger fracture or dislocation. KNEE (AP, LAT & OBLIQUE): No evidence of left knee fracture. Severe degenerative change. CXR ___: Several old left-sided healed rib fractures are seen. Heart size is within normal limits. There is atelectasis at the lung bases, stable. No focal consolidation is seen. There are no pneumothoraces. TTE ___: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global biventricular systolic function. No clinically-significant valvular disease seen. Limited study. =============================== DISCHARGE LABS =============================== No labs drawn at discharge. Brief Hospital Course: MMs. ___ is a ___ year old woman with history of neurocognitive disorder, heart failure, lymphocytic colitis, hypertension and peripheral neuropathy presenting from assisted living (___) with unwitnessed fall, found to have ___ and volume overload on exam. # HYPOXIA #Acute on chronic diastolic heart failure Initially had O2 requirement of ___, not on any home O2. Pt has history of HF. BMP within normal limits, but she presented with elevated JVP, pulmonary edema on CXR, and ___ edema suggestive of fluid overload. Treated in ED for pneumonia, but this was less likely given no cough or fever, and CXR more consistent with pulmonary edema. She was given diuresis with IV Lasix and oxygenation improved. She was restarted home torsemide and remained stable with good oxygen saturation on room air at discharge. For afterload reduction, patient was initially on atenolol, but this was held in the setting of ___. Metoprolol was started in the setting of SVT discussed below. Thus, atenolol was stopped at discharge given baseline CKD. Spironolactone was held given ___ and potassium ___ in the setting of IV lasix. Could consider starting an ACE-inhibitor if not already attempted as an outpatient. TTE revealed normal bi-ventricular systolic function with normal EF (see above). # S/p fall No fractures on XR in ED, CT negative. Patient describes a mechanical fall. Likely secondary to deconditioning and weakness from worsening CHF. Other etiologies include infection (leukocytosis) vs stroke, but these were less likely. The patient was monitored on telemetry (SVT discussed below). ___ was consulted and recommended rehab. Per patient's niece/hcp, has been more weak at home over last several months. # SVT On ___, patient had runs of SVT (lasting seconds on tele) with no symptoms, as well as several PACs. Unclear if has a history of SVT in the past. This was potentially exacerbated by stress from HF exacerbation. She was started on Metoprolol Tartrate 6.25 mg PO/NG Q6H, and transitioned to succinate 25 daily. # ___ on CKD Cr 1.8 on admission. Could be ___ HF exacerbation discussed above. Improved with diuresis to 1.3. Baseline 1.2 per patient's PCP. CHRONIC: # HTN - atenolol held in setting of ___, on metoprolol as discussed above. # Depression - continued sertraline 100. # Lymphocytic colitis - continued home loperimide and budesonide. # Continue vitamin D2. =================================== TRANSITIONAL ISSUES =================================== [ ] New medication: metoprolol succinate 25 daily for SVT. [ ] Atenolol stopped at discharge given that metoprolol was started and has ___. [ ] Spironolactone was held given ___ and potassium ___ in the setting of IV lasix. [ ] Could consider starting an ACE-inhibitor if not already attempted as an outpatient. [ ] F/u BMP in 1 week to monitor renal function and electrolytes. Cr 1.3 at discharge. #Health care proxy: ___ (nephew) ___ ___ and ___ (niece) ___ ___ #Code: DNR/DNI confirmed by ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Budesonide 3 mg PO TID 2. Spironolactone 50 mg PO DAILY 3. Sertraline 100 mg PO DAILY 4. Torsemide 5 mg PO 4X/WEEK (___) 5. Torsemide 7.5 mg PO 3X/WEEK (___) 6. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) 7. Atenolol 50 mg PO DAILY 8. LOPERamide 2 mg PO TID:PRN diarrhea 9. Artificial Tears ___ DROP BOTH EYES PRN dry eye Discharge Medications: 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Artificial Tears ___ DROP BOTH EYES PRN dry eye 3. Budesonide 3 mg PO TID 4. LOPERamide 2 mg PO TID:PRN diarrhea 5. Sertraline 100 mg PO DAILY 6. Torsemide 5 mg PO 4X/WEEK (___) 7. Torsemide 7.5 mg PO 3X/WEEK (___) 8. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) 9. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until your doctor tells you to ___ it Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: -------- - Unwitnessed fall. - Acute exacerbation of chronic heart failure. Secondary: ----------- - Acute kidney injury - Superventricular tachycardia - Depression - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to ___ after a fall. Why was I here? =============== - You had a fall, probably from weakness. - You had a lot of fluid buildup around your lungs and in your legs. What was done for me while I was here? ======================================= - You got a medication called Lasix to remove some of the fluid around your lungs and in your legs. - You had a fast heart rate (supraventricular tachycardia) that was treated with a medication called metoprolol. What do I do when I leave? =========================== - Before you go home, you will go to a rehab. This will help you build your strength. - You have a new medication called metoprolol for your fast heart rate. - You will have labs drawn and a follow up appointment within a week. - Please take your medications as prescribed. Your medications and appointments are below. It was a pleasure taking care of you and we wish you good health. Sincerely, Your ___ Care Team Followup Instructions: ___
19826426-DS-9	19,826,426	29,537,301	DS	9	2149-10-07 00:00:00	2149-10-07 21:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: cough Major Surgical or Invasive Procedure: none History of Present Illness: hpi: ___ yo F with a history of colitis NOS, high blood pressure presenting with 2 days of cough productive of thick white sputum, nausea without vomiting, and malaise. Denies cp/dypnea/f/c. Pt reports being seen by PCP for similar ___ last month and receiving abx. Per OMR, pt saw Dr. ___ received ___ for ? PNA based on exam. No xray done at the time. . Brought in by EMS today: ED Course:Tm 100.3, on tx 98.2 90 137/75 20 98%. cxr: bibasilar opacities. ecg ___ changes. Pt given ___ and tamiflu. flu swab negative. labs unremarkable. . ros: as above. o/w denies abd pain/HA/ weakness or numbness in exts Past Medical History: hypertension colitis, nos pernicious anemia depression Social History: ___ Family History: no family hx heart or lung dz Physical Exam: vs:t98 146/70 p80 r18 95%ra comfortable, nad eomi, perrl b/l rhonchi rrr, no murmurs bad s/nt/nd ext w/wp without edema Pertinent Results: ___ 10:02PM COMMENTS-GREEN TOP ___ 10:02PM LACTATE-1.4 K+-3.9 ___ 09:50PM GLUCOSE-100 UREA N-19 CREAT-0.9 SODIUM-137 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 ___ 09:50PM estGFR-Using this ___ 09:50PM WBC-10.8# RBC-4.11* HGB-13.1 HCT-40.5 MCV-99* MCH-31.8 MCHC-32.3 RDW-12.4 ___ 09:50PM NEUTS-85.1* LYMPHS-8.5* MONOS-3.9 EOS-2.3 BASOS-0.2 ___ 09:50PM PLT COUNT-236 ___ 09:50PM ___ PTT-28.0 ___ CXR IMPRESSION: 1. Bibasilar opacities, which may represent atelectasis, aspiration or infection in the appropriate clinical setting. 2. Hiatal hernia. ___ 11:20 pm Influenza A/B by ___ Source: Nasopharyngeal swab. *FINAL REPORT ___ DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Negative for Influenza B. Brief Hospital Course: A/P: ___ yo woman with hx HTN admitted with cough, malaise, subjective chills, bibasilar infiltrates suggestive of CAP #Pneumonia/CAP: influenza negative - initiated on ceftriazone and ___ and responded well. Ambulatory sat was wnl and respiratory status remained stable throughout hospitalization. Transitioned to cefpodoxime and ___ (to complete 7 day course of cephalosporin, 5 day course of ___ #Nausea: resolved, abdominal exam benign . HTN: Continued on lisinopril, atenolol. She was seen by ___ ___ who confirmed she has active prescriptions with her pharmacy. She is unsure whether she is taking all of her meds at home, but her BPs here indicate she could benefit from continuing them. . Pernicious anemia: cont: b12 . Colitis, NOS: cont entecort . Peripheral neuropathy: continue amitriptyline . hx falls: pt uses cane at baseline. Although pt denies recent falls, OMR notes indicate otherwise. ___ consult pending . FEN: heart healthy diet PPX: hep sc Access: peripheral FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Cyanocobalamin ___ mcg PO DAILY 3. Budesonide 3 mg PO DAILY 4. Atenolol 25 mg PO DAILY 5. Amitriptyline 25 mg PO HS 6. Fluoxetine 10 mg PO DAILY 7. Cyanocobalamin 1000 mcg IM/SC QMONTH Discharge Medications: 1. Amitriptyline 25 mg PO HS 2. Atenolol 25 mg PO DAILY 3. Budesonide 3 mg PO DAILY 4. Cyanocobalamin ___ mcg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Fluoxetine 10 mg PO DAILY 7. Cyanocobalamin 1000 mcg IM/SC QMONTH 8. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 9. Azithromycin 250 mg PO Q24H Duration: 2 Days RX azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #3 Tablet Refills:*0 10. Outpatient Physical Therapy Evaluate and treat. Indication: unsteady gait, history of prior falls. Recent pneumonia hospitalization. Uses cane at baseline. Discharge Disposition: Home Discharge Diagnosis: Community-acquired pneumonia Secondary: Hypertension Depression Pernicious anemia Discharge Condition: condition: stable mental status: lucid ambulatory status: independent with cane Discharge Instructions: You were admitted with a cough, fever/chills, and treated for possible pneumonia with antibiotics. We are giving you a prescription for an oral antibiotic to take at home. Please keep your followup appointment with Dr. ___ as below Followup Instructions: ___
19826427-DS-22	19,826,427	22,111,272	DS	22	2117-08-22 00:00:00	2117-08-23 18:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / naproxen / amlodipine / hydrochlorothiazide / lisinopril Attending: ___ Chief Complaint: Cough Major Surgical or Invasive Procedure: Bronchoscopy (___) History of Present Illness: ============================ HISTORY OF PRESENT ILLNESS: ============================ Mr. ___ is a ___ yo M with history of HTN, hyperlipidemia, asthma, allergic rhinitis, nasal polyps, hypogammabloulinemia on replacement, and severe diffuse tracheobronchomalacia s/p tracheobronchoplasty 2 months ago c/b posterior wall ischemia and pseudomembrane formation, presenting with unremittent cough s/p bronch on ___. He was diagnosed with TBM and treated with airway stenting since ___ with improvement ___ his respiratory symptoms. He underwent right thoracotomy and tracheobronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage on ___. He tolerated procedure well, but post-op course was complicated by respiratory failure due to tracheal edema and pseudomonas pneumonia. On ___, he underwent flexible/rigid bronchoscopy with debridement of granulation tissue and balloon dilatation with biopsy. The procedure went well but was complicated by unremittent cough. He was seen ___ ___ clinic the next day when he was prescribed codeine and tessalon perles. Despite this he continues to have worsening cough which is intermittently productive (tan secretions). he feels better after he's able to bring up some mucous, but it's hard to bring up secretions. He is able to better expel secrestions after taking nebulized bronchodilators. He has had worsening inspiratory and expiratory stridor. Given worsening symptoms he was advised by interventional pulmonology to present to ___ ED. He underwent repeat bronchoscopy ___ w/ repeat balloon dilation, admitted afterwards for IV abx. ___ the ED: Seem by IP, recommended bronchoscopy Initial vital signs were notable for: T 96.7, HR 96, BP 148/83, RR 28, SpO2 99% on RA Exam notable for: stridor, rhonchorous lung sounds bilaterally Labs were notable for: WBC 11.9 Studies performed include: - CXR: Patchy opacities ___ both lung bases and right mid lung field, findings which could reflect multifocal infection or aspiration. - Bronchoscopy with tracheobronchial lavage: showed stable pseudomembrane and narrowing of mid trachea s/p balloon dilation to 10 mm Patient was given: bronchodilator nebs Consults: Interventional pulmonology Vitals on transfer: ___ Temp: 98.8 PO BP: 125/71 L Lying HR: 94 RR: 19 O2 sat: 95% O2 delivery: 2L Upon arrival to the floor, still having significant cough and inspiratory stridor. Now on 2L O2 satting 95%. Past Medical History: Asthma HTN Hyperlipidemia Hypogammabloulinemia Allergic Rhinitis Nasal polyps BPH Ocular Hypertension Tracheobronchomalacia OSA Gout Cellulitis ___ Cholelithiasis (___) Pilonidal Cyst excision Lipoma ___ Social History: ___ ___ History: Mother: ___ cancer, ___, CHF Father: ___ Physical Exam: PHYSICAL EXAM ON ADMISSION: VITALS: ___ Temp: 98.8 PO BP: 125/71 L Lying HR: 94 RR: 19 O2 sat: 95% O2 delivery: 95% on 2L GENERAL: Alert and interactive. Frequent cough and audible inspiratory stridor. HEENT: NCAT. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Increased work of breathing with inspiratory stridor, taking frequent breaths and coughing frequently. Rhonchorous breath sounds throughout lung fields. ABDOMEN: Normal bowels sounds, non distended, non-tender. No rebound or guarding. EXTREMITIES: Warm and well perfused. No clubbing, cyanosis, or edema. NEUROLOGIC: AOx3, no focal deficits. PHYSICAL EXAM ON DISCHARGE: Vitals: ___ 0738 Temp: 97.8 PO BP: 158/96 L Sitting HR: 101 RR: 20 O2 sat: 95% O2 delivery: Ra General: Pale elderly man seated on bed, hoarse voice, uncomfortable appearing but ___ no acute distress. Not coughing. HEENT: Normocephalic, PERRL, EOMI, moist mucus membranes. Neck: Supple, no lymphadenopathy Lungs: Not using accessory muscles, breathing comfortably on room air. Intermittent audible harsh inspiratory breath sounds. Lungs largely clear this morning with harsh transmitted upper airway sounds with no stridor, moving air well CV: Rapid rate, regular rhythm, no murmurs. GI: +BS, non-distended, non-tender. Ext: Warm, well-perfused, no cyanosis or edema. Distal pulses 2+ Neuro: Alert, oriented x3. Readily recalls and discusses recent history ___ detail. Cranial nerves II-XII intact. Moving all extremities equally. Skin: Healing follicular rash on back. Well-healed thoracotomy incision on R side. Pertinent Results: LAB RESULTS ON ADMISSION: ============================ ___ 12:05PM BLOOD WBC-11.9* RBC-3.96* Hgb-12.7* Hct-38.4* MCV-97 MCH-32.1* MCHC-33.1 RDW-13.3 RDWSD-48.0* Plt ___ ___ 12:05PM BLOOD Neuts-74.9* Lymphs-17.4* Monos-6.0 Eos-0.7* Baso-0.3 Im ___ AbsNeut-8.95* AbsLymp-2.07 AbsMono-0.71 AbsEos-0.08 AbsBaso-0.03 ___ 12:05PM BLOOD Plt ___ ___ 12:05PM BLOOD Glucose-121* UreaN-12 Creat-1.1 Na-141 K-4.4 Cl-104 HCO3-22 AnGap-15 ___ 07:15PM BLOOD ALT-10 AST-13 LD(LDH)-111 AlkPhos-58 TotBili-0.4 ___ 12:05PM BLOOD Calcium-9.2 Phos-3.0 Mg-1.7 PERTINENT INTERVAL LABS: =========================== ___ 07:15PM BLOOD IgG-647* LAB RESULTS ON DISCHARGE: =========================== ___ 07:35AM BLOOD WBC-6.6 RBC-3.80* Hgb-12.2* Hct-37.2* MCV-98 MCH-32.1* MCHC-32.8 RDW-13.6 RDWSD-49.4* Plt ___ ___ 07:30AM BLOOD Glucose-80 UreaN-10 Creat-1.0 Na-141 K-4.7 Cl-103 HCO3-25 AnGap-13 ___ 07:30AM BLOOD Albumin-3.4* Calcium-9.2 Phos-2.9 Mg-1.7 MICROBIOLOGY: ============= ___ 11:40 am TISSUE TRACHEAL LESION. FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): YEAST(S). SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final ___: MIXED BACTERIAL FLORA. MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH OROPHARYNGEAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. ___ ALBICANS. QUANTITATION NOT AVAILABLE. WORK UP REQUESTED BY ___ (___) ___. Yeast Susceptibility:. Fluconazole MIC OF 0.25 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. ANAEROBIC CULTURE (Final ___: BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA LACTAMASE POSITIVE. ___ 11:30 am BRONCHIAL WASHINGS TRACHEAL WASH. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final ___: >100,000 CFU/mL Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. ID AND SENSITIVITIES REQUESTED BY ___ ___. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our ___ studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). ___ 5:18 pm BRONCHIAL WASHINGS GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: >100,000 CFU/mL Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): YEAST. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our ___ studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). ___ 7:00 am MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 3:15 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Blood culture ___ negative Serum aspergillus galactomannan negative ___ B-glucan negative ___ PATHOLOGY ========== ___ TRACHEAL BIOPSY SURGICAL PATHOLOGY REPORT - Final PATHOLOGIC DIAGNOSIS: Tracheal lesion: - Extensively necrotic fibrous tissue with acute inflammation. - GMS reveals invasive yeast and fungal hyphae forms. - Gram stain reveals extensive Gram positive cocci and rods. IMAGING ========= CT TRACHEA WITHOUT CONTRAST ___ UNDERLYING MEDICAL CONDITION: ___ gentleman with TBM s/p TBP ___ c/b tracheal ischemia with pseudomembrane, presenting with worsening cough, sputum production, and stridor. REASON FOR THIS EXAMINATION: Eval trachea, patient with history tracheal ischemia w pseudomembrane CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report EXAMINATION: CT TRACHEA W/O CONTRAST INDICATION: ___ gentleman with TBM s/p TBP ___ c/b tracheal ischemia with pseudomembrane, presenting with worsening cough, sputum production, and stridor.// Eval trachea, patient with history tracheal ischemia w pseudomembrane TECHNIQUE: Multi detector helical scanning of the chest was performed at end inspiration, reconstructed as contiguous 5.0 and 1.25 mm thick axial and 2.5 mm thick coronal and sagittal images of the full chest. Multi detector helical scanning of the chest was repeated during forced expiration, and reconstructed as contiguous 5.0 and 1.25 mm thick axial images. Intravenous contrast agent was not employed. DOSE: Total DLP: 613.42 mGy-cm COMPARISON: Chest CT dated ___ and ___. FINDINGS: DYNAMIC TRACHEA CT Patient is status post tracheal broncho plasty complicated by pseudo membrane. Again seen is circumferential wall thickening of the trachea and bilateral mainstem bronchi, worse compared to ___, particularly ___ the posterior aspect of the trachea and bronchi. Again seen is focal tracheal narrowing measuring 1.0 cm at approximately 10 cm from the vocal cord (series 302, image 81), similar to ___, likely corresponding to known pseudomembrane. Tracheal shape ___ end-inspiration: Abnormal Tracheal shape ___ dynamic expiration: Crescent Tracheal collapsibility: 1 cm above the aortic arch (cor x sag; area) Inspiration: 13.8 x 7.2mm,90.5mm2 Expiration: 12.5 x 4.6mm,48.8mm2 (I-E)/I x ___ decrease(CI, collapsibility index) 1 cm above the carina (cor x sag; area) Inspiration: 13.9 x 5.9mm, 71.8mm2 Expiration: 8.7 x 3.3mm, 25.4mm2 (I - E)/I x ___ decrease (CI, collapsibility index) Bronchi collapsibility: Right Main Bronchus, at the level of maximum collapse Inspiration: 2.4mm Expiration: 1.6mm (I - E)/I:x ___ decrease (CI, collapsibility index) Left Main Bronchus, at the level of maximum collapse Inspiration: 3.8mm Expiration: 1.4mm (I - E)/I:x ___ decrease (CI, collapsibility index) Air trapping Moderate (between approximately 30% to 60% of parenchyma with air trapping) ___ the left lower lobe CHEST CT (Non-tracheal findings) The thyroid is unremarkable. No supraclavicular or axillary lymphadenopathy. Scattered subcentimeter mediastinal and bilateral hilar lymph nodes are not enlarged by CT criteria, grossly unchanged compared to ___. No mediastinal mass. The heart size is normal. There are mild coronary artery calcifications. No pericardial effusion. The aorta and pulmonary arteries are normal ___ caliber. No substantial atherosclerotic calcifications seen ___ the great vessels. Multiple solid nodules ___ right upper lobe (series 302, image 86 and 104), right middle lobe (series 302, image 157), right lower lobe (series 302, image 174), and left lower lobe (series 302, image 148) are unchanged. No new or growing pulmonary nodules. There are bibasilar atelectasis. Scatter ___ nodular opacities ___ the right upper lobe (series 302, image 108) most likely represent aspiration. There are bilateral lower lobe bronchial wall thickening with mucous plugging. No pleural effusion or pneumothorax. No acute fracture or suspicious osseous lesions. Degenerative changes of the thoracic spine are moderate. Limited evaluation of the upper abdomen is unremarkable. IMPRESSION: 1. Worsening circumferential wall thickening of the trachea and bilateral mainstem bronchi compared to ___, particularly ___ the posterior aspect. 2. Redemonstration of focal tracheal narrowing measuring approximately 1.0 cm at approximately 10 cm from the vocal cord, likely corresponding to known pseudomembrane. 3. Right upper lobe scattered ___ nodular opacity, most likely representing aspiration. 4. Bilateral lower lobe bronchial wall thickening with mucous plugging. OPERATIVE REPORT ___ Surgeon: ___, MD ___ PREOPERATIVE DIAGNOSIS: Severe diffuse acquired tracheobronchomalacia. POSTOPERATIVE DIAGNOSIS: Severe diffuse acquired tracheobronchomalacia. PROCEDURE PERFORMED: Right thoracotomy and tracheobronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage. ASSISTANT: ___, MD ANESTHESIA: General endotracheal. INTRAVENOUS FLUIDS: 1500 mL. URINE OUTPUT: 700 ESTIMATED BLOOD LOSS: 300. INDICATIONS FOR PROCEDURE: Mr. ___ is a ___ gentleman with tracheomegaly and tracheobronchomalacia. He has significant cough as his primary symptom. He had stents placed which seemed to mitigate the cough somewhat but not completely. The stents have been ___ many months and had suffered fracture and infection. We recommended that these be removed which he had done approximately one month prior. We gave him just over three weeks to allow the airway to heal. A followup bronchoscopy showed some chronic inflammation ___ the airway and severe collapse. The patient was turned into the right thoracotomy and prepped and draped ___ the usual sterile fashion. He received general anesthesia and then a modified 39 cut endobronchial tube was placed. We then did a standard posterolateral thoracotomy dividing the latissimus but sparing the serratus and shingling the fifth rib posteriorly. We then dissected free the azygous arch and doubly ligated with ___ silk. We then incised the pleura on the back wall of the airway from the thoracic inlet all the way down distally until we can dissect out the distal left mainstem bronchus, the right-sided airways, and the entirety of the thoracic trachea. We did our dissection from cartilage edge to cartilage edge and took care not to venture too far on the lateral wall of the airways so as not to create ischemia. Once we had the airway cleaned off, we took measurements. The airway was quite large with a proximal tracheal diameter of 48 mm, distal trachea 45 mm, right mainstem bronchus 33 mm, bronchus intermedius 23 mm, and left mainstem bronchus 27 mm. We took a polypropylene mesh ___ the shape of a Y, so that the proximal tracheal limb would eventually be 23 mm, distal 22 mm, right mainstem bronchus 24 mm, bronchus intermedius 16 mm, and left mainstem bronchus 20 mm. We then began to suture the airway into place. Unlike our usual customary rows of four because of the significant airway width, we used rows of five across the distal trachea, five across the mainstem, two membranous sutures ___ the middle of the ventral triangle and then five across the left main stem. The sutures were attempted to be placed ___ partial thickness fashion. ___ the membranous all we used horizontal mattress sutures to gather little bit more of the access when we could. We then parachuted this mesh into place and tied all the sutures and then worked from distal proximal on the trachea. We spaced the rows on the airway about every 8-9 mm apart and the rows on the mesh were closer to about 5 to 7 mm apart so we can get a little bit of axial tension as well. We noted that the cartilage was somewhat deformed so that it bowed inward just past the lateral wall so we had to take care not to create an omega shape to the airway with lateral narrowing. We took the suture rows all the way up to the thoracic inlet and then tucked about 0.5 cm mesh above that level. We then did the right mainstem bronchus suturing all the way to the distal bronchus intermedius. The right mainstem was highly deformed and was difficult to actually recreate an arch, but ultimately we were happy that we created stability of that back wall there and then we did a similar rows of sutures on the left mainstem bronchus with similar challenges with the cartilage malformation. The mainstem bronchus cartilage was actually nearly inverted ___ an upside down U, so turning it back into standard arch was nearly impossible. Never the less we thought we had achieved some AP diameter which he had not had before. Once the suturing was finished, we irrigated with bacitracin irrigation, placed a ___ drain. We closed the ribs back together with #2 fiber wire and then re-tacked the serratus with 0-Vicryl and reapproximated Latissimus with 0-Vicryl and closed with subcutaneous tissue with ___ Vicryl and the skin with ___ Vicryl. At the completion of the operation, we did a bronchoscopy, and we noted that his airways were highly inflamed. We used several Aliquots of saline to lavage free the airway secretions ___ the distal airways. He did have some turbid and mucoid secretions especially ___ the left lower lobe, but we were able to lavage this free. We did send an Aliquot for culture. Brief Hospital Course: Mr. ___ is a ___ with hx of asthma, allergic rhinitis, hypogammaglobulinemia (on IVIG), and severe tracheobronchomalacia s/p tracheobronchoplasty 2 mo ago c/b posterior wall ischemia and pseudomembrane formation, now presenting with uncontrollable cough after his most recent bronchoscopy on ___, with CXR and bronch ___ concerning for infection. Tracheal biopsy showed invasive yeast/fungal hyphae ___ a background of necrotic tissue. ============= ACUTE ISSUES: ============= #Cough #Leukocytosis #Concern for invasive yeast # Respiratory tract infection: As above concern for infection ___ Patient presented with acutely worsening cough after bronchoscopy on ___ by the interventional pulmonary team. He had productive cough at baseline; there was no change ___ purulence. Leukocytosis to ~12K at admission declining on abx, 6.6 by discharge. CXRs during his stay were unremarkable and unchanged from baseline. A CT trachea on ___ was notable for increased edema, increased stenosis (s/p balloon dilation on bronch), and e/o aspiration which likely caused lower respiratory infection/pneumonia. Given the patient's history of Pseudomonas, slowly healing posterior tracheal membrane with mesh ___ place, and frequent instrumentation, he was treated for potential tracheitis ___ collaboration with the infectious disease team. Of note, his tracheal tissue biopsy of ___ showed invasive yeast/hyphae ___ necrotic tissue. Microbiology during his stay was notable for bronchial lavage and biopsy microbiology from ___ and ___ which showed commensal respiratory ___ albicans sensitive to fluconazole, and Bacteroides. His blood cultures were consistently negative. He was treated with antibiotics throughout stay vanc/zosyn (___) --> vanc/cefepime/flagyl + voriconazole ___ levofloxacin/flagyl/voriconazole (___) for respiratory tract infection Regarding concern for invasive fungal forms seen on biopsy- ___ our discussions with microlab who reviewed slide- there are few budding yeast ___ midst of necrotic debris. Per IP, biopsy likely included some live tissue and there was bleeding with the biopsy; hence the concern would be that there is live tissue adjacent to the infected area that was biopsied. ___ addition, if his suture line/mesh were to get infected on the posterior wall of the trachea, it is thought that there would be no further surgical options available. B-D-glucan and galactomannan results are both negative, which is some reassurance against an invasive fungal process. However, given high risk, ID and IP would still favor a 6 week course of oral levofloxacin/flagyl/voriconazole for at least 6 wks, with interval bronchoscopy to help determine the total course. His symptoms were managed with guaifenesin-codeine, tessalon pearls, standing duonebs, and a flutter valve. Otherwise, there was no evidence of URI or allergies throughout his stay. There was concern for aspiration given CT findings and his coughing: see below. # Aspiration CT showed evidence of aspiration. No clinical or CXR evidence of aspiration PNA during his stay. The speech and language pathology team evaluated him and recommended an NPO diet initially due to concern over poor airway protection due to his coughing. This was advanced on their recommendations during his stay. At discharge he was on a regular diet. # Hypogammaglobulinemia. A chronic issue for the patient. He was receiving IVIG every 28 days for ___ yrs prior to admission, but had missed his dose ___ ___. IVIG 25 gm was administered ___. =============== CHRONIC ISSUES: =============== # Asthma/allergic rhinitis: Per patient there was no increase ___ albuterol requirement prior to admission and no recent allergies that could be a precipitant of his cough. During his stay he was continued on his home singulair and fluticasone. Standing duonebs were also administered during his stay. # HTN: Home diltiazem was held given normotensive on admission; he was discharged without diltiazem given interactions with voriconazole (also note this is atypical choice of medication). SBPs ___ 120-140s at discharge. Not replaced given allergies to lisinopril, thiazides, and amlodipine which were documented but patient unable to specify. ___ consider ___ or BB such as carvedilol pending clarification of patient's lisinopril allergy. # Hyperlipidemia: Home simvastatin was held given interaction with voriconazole. Please note that atorvastatin also has interaction with voriconazole. # BPH: Home finasteride was continued and his tamsulosin was held given interaction with voriconazole. Terazosin (a home med) was restarted instead. There was no urinary retention during his stay. He was discharged on finasteride and terazosin. # Depression: Home citalopram was held during part of his stay given interactions with voriconazole and levofloxacin; he was discharged off citalopram. =================== TRANSITIONAL ISSUES =================== # Cough # Leukocytosis # Concern for fungal tracheal infection # Respiratory tract infection [] Discharged on PO course of levofloxacin 750 mg daily /metronidazole 500 mg q8H /voriconazole 200 mg Q12H with ID recommendation to continue for 6 wks (D1 = ___, projected end ___ [] Please check CBC with differential and LFTs weekly while on voriconazole [] IP and thoracic surgery recommend hyperbaric oxygen therapy to promote tracheal healing [] Please help patient f/u with interventional pulmonary, at ___ or elsewhere as appropriate, for evaluation of tracheal healing [] Please help the patient return to infectious disease clinic at end of 6 week course for reevaluation- we are happy to see him at ___ he also has plans to go back to ___ [] Patient has benefited from guaifenesin with codeine and tessalon pearls for cough # Medication changes for interactions with levofloxacin and voriconazole - Due to levoflox/voriconazole, the following medications were held or changed during his stay: - Citalopram 20 mg daily (QTc 497 on day of discharge) - Simvastatin 5mg daily - Diltiazem 60 mg Q6H. SBPs ___ 120-140s at discharge. Not replaced given allergies to lisinopril, thiazides, and amlodipine which patient was unable to specify; may consider carvedilol ___ pending further clarification of allergies - Tamsulosin 0.4 mg QHS, added terazosin 0.4 mg QHS instead. Continued home finasteride. No urinary retention was noted during this admission. [] Please review these medications and consider changing or adding back as appropriate. # Aspiration - Evidence of aspiration on CT (RUL ___ opacities) - SLP with concern for airway protection during inexorable coughing - Cleared for regular diet by discharge [] Please consider re-evaluation by SLP if patient's cough worsens or as appropriate # Hypogammaglobulinemia. - Patient received IVIg 25 mg ___ [] Please help patient arrange Q4wk IVIg infusions; next due ___ # Coping: [] Patient has experienced prolonged stay and would benefit from continued social work support as well as spiritual care #CODE: Full code #CONTACT: ___ Relationship: wife Cell phone: ___ ___ on Admission: 1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 2. Citalopram 20 mg PO DAILY 3. Montelukast 10 mg PO DAILY 4. Simvastatin 5 mg PO QPM 5. Diltiazem 60 mg PO Q6H 6. Docusate Sodium (Liquid) 100 mg PO BID 7. GuaiFENesin 10 mL PO Q6H 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 9. QUEtiapine Fumarate 50 mg PO PRN insomnia, agitation 10. Sodium Chloride 3% Inhalation Soln 5 mL NEB BID 11. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheezing 12. Finasteride 5 mg PO DAILY 13. Fish Oil (Omega 3) 1000 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Privigen (immun glob G(IgG)-pro-IgA ___ 10 % injection Monthly 16. Tamsulosin 0.4 mg PO QHS 17. Vitamin D 1000 UNIT PO DAILY 18. Fluticasone Propionate 110mcg 2 PUFF IH BID 19. Senna 8.6 mg PO BID 20. Ciprofloxacin HCl 750 mg PO Q12H 21. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 22. Acetylcysteine 20% ___ mL NEB BID 23. Albuterol 0.083% Neb Soln 2 NEB IH Q4H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Headache 2. Benzonatate 100 mg PO TID 3. Calcium Carbonate 500 mg PO QID:PRN indigestion 4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 5. Levofloxacin 750 mg PO DAILY 6. MetroNIDAZOLE 500 mg PO/NG Q8H 7. Terazosin 1 mg PO QHS 8. Voriconazole 200 mg PO Q12H 9. Albuterol 0.083% Neb Soln 2 NEB IH Q4H 10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN wheezing 11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 12. Docusate Sodium (Liquid) 100 mg PO BID 13. Finasteride 5 mg PO DAILY 14. Fish Oil (Omega 3) 1000 mg PO DAILY 15. Fluticasone Propionate 110mcg 2 PUFF IH BID 16. GuaiFENesin 10 mL PO Q6H 17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 18. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 19. Montelukast 10 mg PO DAILY 20. Multivitamins 1 TAB PO DAILY 21. Privigen (immun glob G(IgG)-pro-IgA ___ 10 % injection Monthly 22. Senna 8.6 mg PO BID 23. Sodium Chloride 3% Inhalation Soln 5 mL NEB BID 24. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Discharge Diagnosis: #Cough #Leukocytosis #Tracheitis #Invasive fungal infection of trachea #Aspiration #Hypogammaglobulinemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I ___ THE HOSPITAL? You were ___ the hospital because you were coughing uncontrollably after a bronchoscopy. WHAT HAPPENED TO ME ___ THE HOSPITAL? While you were ___ the hospital, you received another bronchoscopy. Your medications to help control coughing were adjusted. You were also treated with antibiotics for possible causes of infection. You were also started on antifungal medication because yeast was found to be growing ___ your trachea. You were discharged after your cough resolved and with an oral regimen of antibiotics and antifungals. You were transferred to ___ for management by thoracic surgery there and for hyperbaric oxygen therapy at ___. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? It is important that you continue to take your medications. You should take the antibiotics, levofloxacin and flagyl, as well as the antifungal, voriconazole, for six weeks. You should follow-up with an infectious disease disease team, either here at ___ or back ___ ___, after you are discharged from ___. During the time you take these medications, you should get weekly labs to check for adverse effects. Your team at ___ will help monitor your response to hyperbaric oxygen therapy and will help arrange bronchoscopy to assess for improvement. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19826582-DS-13	19,826,582	25,324,563	DS	13	2187-12-18 00:00:00	2187-12-18 09:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Grass ___ Blue, Standard / Tree Pollen / Solu-Medrol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / balsam of ___ / shellac / formaldehyde Attending: ___. Chief Complaint: Acute cholecystitis and necrotic gallbladder Major Surgical or Invasive Procedure: Lap-->open cholecystectomy c/b bile leak, failed ERCP, PTBD placement History of Present Illness: ___ yo F with PMH of Roux-en-Y gastric bypass in ___ and ___ esophagus who p/w ___ epigastric non-radiating pain worsening after meals, nausea, vomiting, and diarrhea on ___. She denied jaundice, white stools, fever, chills, or bloody stools or emesis. Past Medical History: Past Medical History: 1. Depression. 2. Multiple sclerosis ___ years. 3. Hypothyroidism. 4. Migraine headaches. 5. Irritable bowel syndrome, asymptomatic at this point. 6. Iron deficiency anemia. 7. Fatty liver. 8. Moderate splenomegaly based on ultrasound. 9. PICC line associated thrombus ___. 10. Mild sleep-disordered breathing consistent with upper airway resistance syndrome. 11. ___ esophagus Past Surgical History: 1. Partial glossectomy for cancer, ___. 2. Port-A-Cath ___ w/ removal. 3. Tonsillectomy ___. 4. Lap Roux-en-Y gastric bypass ___. Social History: ___ ___ History: Father with heart disease, hyperlipidemia, and diabetes mother with thyroid disorder. Physical Exam: Vitals: T 98.2 HR 77 BP 125/68 RR 18 O2 Sat 100/RA General: NAD, A&Ox3 CV: RRR w/ no MRG Pulm: CTAB w/ no C/R/W Abd: S/NT/ND; incisions c/d/i TLD: JP w/ bilious drainiage, R PTBD w/ bilious drainage Extremities: warm, well-perfused, no edema Pertinent Results: --CBC-- ___ 05:10AM BLOOD WBC-15.9* RBC-2.98* Hgb-8.3* Hct-25.6* MCV-86 MCH-27.9 MCHC-32.4 RDW-14.1 RDWSD-43.2 Plt ___ Neuts-83* Bands-1 Lymphs-8* Monos-3* Eos-1 Baso-0 Atyps-0 Metas-4* Myelos-0 AbsNeut-13.36* AbsLymp-1.27 AbsMono-0.48 AbsEos-0.16 AbsBaso-0.00* Plt Smr-HIGH Plt ___ ___ 04:34AM BLOOD WBC-21.9* RBC-3.49* Hgb-9.7* Hct-30.2* MCV-87 MCH-27.8 MCHC-32.1 RDW-14.2 RDWSD-44.4 Plt ___ Plt ___ ___ 05:21AM BLOOD WBC-15.9* RBC-2.90* Hgb-8.1* Hct-25.6* MCV-88 MCH-27.9 MCHC-31.6* RDW-14.5 RDWSD-46.5* Plt ___ ___ 10:40AM BLOOD WBC-24.2* RBC-3.62* Hgb-10.0* Hct-32.2* MCV-89 MCH-27.6 MCHC-31.1* RDW-14.3 RDWSD-46.4* Plt ___ --Chem-- ___ 05:10AM BLOOD Glucose-85 UreaN-6 Creat-0.5 Na-139 K-3.5 Cl-104 HCO3-22 AnGap-17 --LFTs-- ___ 05:10AM BLOOD ALT-20 AST-40 AlkPhos-94 TotBili-0.3 ___ 04:34AM BLOOD ALT-12 AST-22 AlkPhos-108* TotBili-0.3 --Other-- ___ 05:10AM BLOOD Albumin-2.3* Calcium-7.9* Phos-3.3 Mg-1.9 ___ 12:40PM BLOOD Lipase-30 --Urine-- ___ 01:53PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 01:53PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG ___ 01:53PM URINE RBC-1 WBC-7* Bacteri-FEW Yeast-NONE Epi-<1 ___ 01:53PM URINE CastHy-3* ___ 01:53PM URINE Mucous-OCC Brief Hospital Course: U/S on ___ was c/w acute cholecystitis. The patient underwent a lap cholecystectomy on ___, however the gallbladder was noted to be gangrenous and the case was converted to open. The patient tolerated the procedure well. Post-op, she was noted to have increased bilious drainage from her JP drain. MRCP on ___ noted a bile leak, and ERCP was attempted on ___ but failed given the anatomy post-Roux-en-Y. ___ placed a R posterior ___ PTBD on ___. Following this, appropriate drainage from the PTBD was noted and her JP drainage decreased. Her sx are resolved and LFTs/bilis are wnl. Her WBCs are down-trending though still elevated at 15.9. Given this and persistent loose stools, stool was sent for C. diff testing, results are pending and will become available after discharge. Medications on Admission: ACETAMINOPHEN-CODEINE - acetaminophen 300 mg-codeine 60 mg tablet. one tablet(s) by mouth q4-6 hrs as needed for migraine or severe menstrual cramps CETIRIZINE [ZYRTEC] - Zyrtec 10 mg tablet. 1 tablet(s) by mouth daily as needed for allergies - (Prescribed by Other Provider) CITALOPRAM - citalopram 40 mg tablet. 1.5 tablet(s) by mouth Daily CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000 mcg/mL injection solution. 1 injection Monthly - (Prescribed by Other Provider) LEVOTHYROXINE - levothyroxine 150 mcg tablet. one Tablet(s) by mouth daily LORAZEPAM - lorazepam 0.5 mg tablet. one tablet(s) by mouth twice a day as needed TOPIRAMATE - topiramate 50 mg tablet. three tablet(s) by mouth HS OTC - CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE +] - Calcium Citrate + 315 mg-200 unit tablet. tablet(s) by mouth twice a day - (OTC) CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 5,000 unit capsule. 1 Capsule(s) by mouth Daily - (Prescribed by Other Provider) IRON, CARBONYL [IRON CHEWS] - Iron Chews 15 mg tablet. two tablet(s) by mouth daily - (OTC) MULTIVITAMIN [CHEWABLE-VITE] - Chewable-Vite tablet. two tablet(s) by mouth daily - (OTC) RIBOFLAVIN (VITAMIN B2) - riboflavin (vitamin B2) 100 mg tablet. 4 tablet(s) by mouth daily - (Not Taking as Prescribed) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate please take with food. do not drink or drive when taking. RX oxycodone 5 mg ___ tablet(s) by mouth Q4 Disp #15 Tablet Refills:*0 3. Cetirizine 10 mg PO DAILY 4. Citalopram 60 mg PO DAILY 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Omeprazole 20mg QD Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking care of you here at ___ ___. You were admitted to our hospital abdominal pain with acute cholecystitis/ necrotic gallbladder . Please follow up with Interventional Radiology regarding her PTBD tube (see appointments). Your ___ will help with drain care as long as the PTBD is in place. Please follow up with general surgery (see appointments) in regards to your JP drain. Your ___ will help with drain care as long as the PTBD is in place. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - You may start some light exercise when you feel comfortable. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. - You may have a sore throat because of a tube that was in your throat during the endoscopy. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. - After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluitds and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
19826583-DS-20	19,826,583	28,650,529	DS	20	2124-06-29 00:00:00	2124-06-29 13:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left arm and leg jerking Major Surgical or Invasive Procedure: MRI History of Present Illness: ___ is an ___ year-old woman with history of R-MCA stroke last year also hypertension, hyperlipidemia and other chronic conditions (as below). She has never had a seizure before, and no major Neurologic history besides the stroke last year. For details regarding the stroke history, please see detailed notes in ___ from ___ initail presentation and evaluation by our ___ vascular Neurology team, as well as Dr. ___ clinic ___ notes, in ___ and ___ of this year. The history of today's episode is a bit fragmented, with a bit of information from the patient (somnolent s/p Ativan in ED) from her daughter (who was at work until arrival in ED just now) and from ED physicians' reports. It seems that the patient was in her USOH, at home, when around 4pm she developed "twitching in my hand." The twitching spread -- within minutes, per pt. -- to involve the whole arm and then the leg. She cannot recall whether her face was twitching. She activated EMS, who had to break down her door. She continued having Left arm and leg rhythmic jerking movements on arrival to our ED, where she was reoprtedly lucid with normal speech and language and A&Ox3 (per ED resident). The rhythmic jerking movements of her Left foot/ankle were recorded on a brief iphone video, which I reviewed. She was given 1mg IV lorazepam, which reduced the jerking movements somewhat, and then an additional 1mg IV lorazepam, at which point the movements stopped. A ___ was ordered. We were consulted to evaluate the patient for seizure. I asked the ED physicians to hold off on further medications or tests until I evaluated her. She says she has never seized and never experienced any episodes like this. She denies recent illness. Denies toxic or illicit ingestion or any recent medication changes (although she seems too somnolent/inattentive for reliability at this time). Review of Systems: denies pain, recent illness; ROS is quite limited due to somnolence. Past Medical History: 1. Right MCA (inferior M2 branch) infarct ___ (see extensive ___ Neurology notes and imaging studies from that time), with hemorrhagic conversion. Baseline as above. Followed in clinic by Dr. ___ seen in ___ with unremarkable exam and no changes to plan. ?cardioembolic. Some ectopy on cardiac rhythm monitoring, but never afib/flutter. 2. hypertension 3. anemia 4. glaucoma 5. ?dementia 6. uterine prolapse w/pessery 7. OP 8. L1 compression fracture 9. left inguinal hernia 10. sigmoid diverticulitis 11. right iliopsoas bursitis 12. bilateral renal cysts 13. chronic constipation 14. hyperlipidemia Social History: ___ Family History: Mother - ___ Father - died old age Brother - prostate ca Brother - ca unspecified site Sister - oesophageal ca Physical Exam: General: Somnolent. Cachectic. Sleeping, neck/head slumped to the Right with bed at 90deg. NAD. HEENT: Atraumatic. Anicteric. Mucous membranes are slightly dry. No lesions in oropharynx. Neck: Supple. No carotid bruits appreciated. No lymphadenopathy. Pulmonary: Lungs CTA bilateral bases. Non-labored breathing. Cardiac: RRR, no loud M/R/G appreciated in loud ED trauma bay. Abdomen: Soft, non-tender, and non-distended. Extremities: Warm and well-perfused. No ankle edema. Intact distal pulses. Skin: no gross rashes or lesions noted. ***************** Neurologic examination: Mental Status: Alert, oriented to person, date and time. Dysarthric/slurred speech. -Cranial Nerves: I: Olfaction not tested. II: PERRL, 3 to 2mm (possibly slight anisocoria -- Left <0.5mm larger). Blinks to threat left and right. Resists fundoscopy. III, IV, VI: EOMs full and conjugate; no nystagmus in primary position. End-gaze nystagmus several beats, few more beats on Left ward gaze than on rightward gaze. Droopy eyelids bilaterally (somnolent). V: Facial sensation grossly intact to pin and LT bilaterally. VII: Left lower facial weakness with contracture @L cheek. VIII: Hearing grossly intact bilaterally. IX, X: Palate elevates with phonation. Breathing regular. XI: ___ equal strength in trapezii bilaterally. XII: Tongue protrusion is midline. -Motor: Diffusely cachectic. Left fingers are contracted. Tone is decreased in Left arm (except fingers) and leg. No spasticity. Full strengh on right upper and lower extremities. On the left, delt is ___, biceps,triceps 4+/5, finger extensors ___. severe contractures of left hand. Quad/IP/Hamstrings ___, 4+on dorsiflexion and plantar flexion. -Sensory: says she can feel pin and light touch in both sides of face and all four extremities. -Reflexes (left; right): diffusely hyporeflexic. Toes equivocal responses bilaterally (neither were up-going). -Coordination: no gross ataxia/titubation. -Gait: requires at least 2 person assistance due to left sided weakness. Pertinent Results: ___ 05:00PM GLUCOSE-114* UREA N-25* CREAT-1.1 SODIUM-144 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-27 ANION GAP-14 ___ 05:00PM estGFR-Using this ___ 05:00PM ALT(SGPT)-13 AST(SGOT)-21 LD(LDH)-257* ALK PHOS-40 TOT BILI-0.3 ___ 05:00PM CK-MB-4 cTropnT-<0.01 ___ 05:00PM ALBUMIN-4.6 CALCIUM-9.9 PHOSPHATE-5.0* MAGNESIUM-2.1 ___ 05:00PM TSH-2.9 ___ 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 05:00PM WBC-8.8# RBC-4.02# HGB-11.5 HCT-36.7# MCV-91 MCH-28.5 MCHC-31.2 RDW-13.9 ___ 05:00PM NEUTS-73.3* ___ MONOS-4.0 EOS-0.5 BASOS-0.2 ___ 05:00PM PLT COUNT-249 ___ 05:00PM ___ PTT-38.3* ___ Brief Hospital Course: Mrs. ___ was admitted on ___ to the neurology floor. She was initially started on keppra 750mg BID, which we increased to 1000 mg the next day due to more episodes of left sided twitching. We increased it again to 1250mg the following day for the same reason. She had fewer episodes of twitching, but they were not fully controlled. We therefore increased the keppra on ___ to 1500mg BID. Her mental status returned quickly to baseline, but she continued to have left sided weakness, but it was unclear whether it was the same as baseline. She however was unable to walk as she used to at home, and therefore we obtained a Brain MRI which did not show any new strokes or acute processes. She had another twitching episode on ___ of unclear duration, we therefore increased her keppra to 1500mg BID. We placed her on LTM on ___, and it did not show any seizures. On admisison, we found she had a UTI on U/A and therefore started her on bactrim. The culture showed mixed flora. We repeated the U/A 5 days after starting the bactrim and it continued to be strongly positive. We therefore switched her to cefpodoxime (PO because we are planning for discharge). Medications on Admission: 1. aspirin 325mg daily 2. lisinopril 40mg daily 3. metoprolol succinate 100mg daily 4. amlodipine 5mg daily 5. simvastatin 40mg daily 6. alendronate 70mg q.wk 7. omeprazole EC 20mg daily 8. dorzolamide 2% eye gtt ___ bid 9. latanoprost 0.005% gtt ___ 10. lactulose 10g/15mL 11. docusate 12. PRN Mg-citrate 13. lactobacillus acidophilus 14. lactose-free food supplements Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever>101. 4. senna 8.6 mg Tablet Sig: ___ Tablets PO HS (at bedtime). 5. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every ___. 9. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 11. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic BID (2 times a day). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 13. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 16. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Seizures Discharge Condition: Discharge condition: good. Mental status: oriented, intact language, slightly disarthric. Ambulatory status: needs at least 2 person assist, remains unstable mostly due to her left sided weakness. Discharge Instructions: Dear ___, ___ were admitted to the neurology service because of new onset of seizures. Your seizures consisted of twitching of your left arm. We believe this is due to your old stroke, which can increase your risk of having this type of seizures. We started ___ on a seizure medication called Keppra (also called Levetiracetam), and we have increased the dose until ___ had no further seizures. ___ will continue to take 1500mg twice a day. We obtained a brain MRI in order to make sure ___ do not have a new stroke, and the MRI did not show any acute changes from your last MRI. We have made some changes to your blood pressure meds because your heart rate has been low, and therefore we cut the amlodipine in half (from 5 to 2.5mg), and stopped your metoprolol. We have also decreased your lisinopril to 30mg daily instead of 40mg as your blood pressure was also low. We started ___ on an antibiotic because ___ had a urinary tract infection. When we checked the urine agian 5 days later it was still positive and this is why we changed the antibiotic to cefpodoxime. Followup Instructions: ___
19826583-DS-21	19,826,583	28,265,770	DS	21	2124-11-24 00:00:00	2124-11-24 16:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Seizure activity Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old right-handed woman with PMH significant for R MCA stroke in ___ and seizures who presents with seizure. Regarding her prior seizure history; her first seizure was in ___, she had shaking of her left hand which spread to her left arm and leg with preserved consciousness. She was admitted to the Neurology service, where she was started on Keppra and this was titrated up to a dose of 1500 mg bid due to continued episodes of left sided seizure activity. She says that since her discharge, up until today, she has not had any further seizures. Her Keppra dose was adjusted in ___ for increased fatigue; her current dose is Keppra 1000 mg qAM and 1500 mg qPM. Regarding today's events, she says she was sitting in the kitchen when her left arm started twitching and this then spread to her left leg. She does not believe there was any facial involvement. No changes to her speech or level of consciousness during the seizure. She says the twitching persisted so she called EMS who brought her to ___. At the time of arrival to ___, she says her twitching had been occuring for about 1 hour. Of note, she believes that her left side was weaker yesterday compared to her baseline. She says she was unable to support herself with her left arm when trying to stand from seated position. She also had to switch from a cane to a walker to ambulate because her left leg was weaker and she even thought she might need a wheelchair. She says that aside from the Keppra dose change in ___, she has not had any recent medication adjustments. She does not note any recent illnesses. No URI symptoms, cough, diarrhea (though she notes loose stool about 1 week ago), rash or dysuria. Neuro ROS: Positive for left sided weakness at baseline, worse since yesterday and left arm and leg seizure activity today. No headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. No difficulties producing or comprehending speech. No focal numbness, parasthesiae. She reports history of bowel, but not bladder incontinence. Difficulty with gait due to increasing left leg weakness, as per HPI. General ROS: no fever or chills. No cough, shortness of breath, chest pain or tightness, palpitations. No nausea or vomiting. She notes alternating periods of loose stool with constipation. No abdominal pain. No dysuria. No rash. Past Medical History: 1. Right MCA (inferior M2 branch) infarct ___ (see extensive ___ Neurology notes and imaging studies from that time), with hemorrhagic conversion. Baseline as above. Followed in clinic by Dr. ___ seen in ___ with unremarkable exam and no changes to plan. ?cardioembolic. Some ectopy on cardiac rhythm monitoring, but never afib/flutter. 2. hypertension 3. anemia 4. glaucoma 5. ?dementia 6. uterine prolapse w/pessery 7. OP 8. L1 compression fracture 9. left inguinal hernia 10. sigmoid diverticulitis 11. right iliopsoas bursitis 12. bilateral renal cysts 13. chronic constipation 14. hyperlipidemia Social History: ___ Family History: Mother - ___ Father - died old age Brother - prostate ca Brother - ca unspecified site Sister - esophageal ca Physical Exam: Vitals: T: 98 P: 61 R: 18 BP: 173/104 SaO2: 96% RA General: Awake, cooperative HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, Pulmonary: lcta b/l Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft, NT/ND, +BS Extremities: warm, well perfused Neurologic: Mental Status: Awake, alert, oriented to person, place and date. Attentive, able to name ___ backward, but slowly. Able to follow both midline and appendicular commands. No right-left confusion. Able to register 3 objects and recall ___ at 5 minutes ___ with prompting). No evidence of apraxia or neglect Language: speech is clear, fluent, nondysarthric with intact naming, repetition and comprehension. Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1 mm. VFF to confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: left facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Decreased muscle bulk throughout, but more notable in left upper and lower extremity. Left pronator drift. She has contractures of fingers, three through five on the left hand (strength for finger flexion and extension noted below is therefore for digits ___. Initially she had rhythmic twitching activity in left lower extremity. This stopped with 1 mg Ativan. Later, while still in ED, she developed rhythmic activity of her left upper extremity. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 4 5- ___ ___- 2 4 4 R 5 ___ ___ 5 5 5 5 Sensory: Diminished pinprick left upper extremity compared to right. She has diminished proprioception at the great toe, more notable on the left. Vibratory sense is absent at the left great toe. She extinguishes the left on DSS. DTRs: Bi Tri ___ Pat Ach L 2 2 2 0 0 R 1 1 1 0 0 Plantar response was mute bilaterally. Coordination: She has dysmetria with intention tremor on finger-nose-finger on left. Also with ataxia when trying to touch examiner's finger with her toe on left. RAMs slower and clumsier on left. Gait: deferred DISCHARGE EXAMINATION: Motor was still noted to be decreased in the left hemibody with improvement of strength over the course of admission to 4+/5- of upper extremity, and 4 to 5 in lower extremity. Sensation remained decreased globally in the left hemibody to all modalities with neglect of left hemibody when bilaterally challenged. Pertinent Results: ___ 11:58PM cTropnT-<0.01 ___ 04:00PM GLUCOSE-138* UREA N-21* CREAT-0.8 SODIUM-141 POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16 ___ 04:00PM estGFR-Using this ___ 04:00PM CALCIUM-10.0 PHOSPHATE-3.3 MAGNESIUM-1.9 ___ 04:00PM WBC-5.6 RBC-3.78* HGB-11.1* HCT-35.5* MCV-94 MCH-29.3 MCHC-31.2 RDW-13.7 ___ 04:00PM NEUTS-66.0 ___ MONOS-3.7 EOS-0.7 BASOS-0.4 ___ 04:00PM PLT COUNT-221 ___ 03:35PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG MRI HEAD IMPRESSION: Sequela of prior right parietal ischemic event with associated encephalomalacia, gliosis and cortical laminar necrosis. No new area of ischemia. EEG FINAL PENDING Brief Hospital Course: Ms. ___ is an ___ year old woman s/p R MCA stroke who presented with with perceived worsened weakness along left side yesterday. While walking she noticed that she couldn't grip the left arm onto a railing and walking was more difficult especially with the left leg. About a half hour later she started noticing the left arm twitching and spread to left leg. She had preserved consciousness and the duration of the even was quite long, persisting until arrival to the ___ ED, resolving with 1mg ativan. She had another episode of clonic activity following the first one which resolved with 1mg ativan and keppra 1g load. She has had no events since the night of admission. She continued to feel well. On exam she remained quadriparetic but with obvious hemiparesis on the left. She had tactile neglect but is fully alert, awake, fluency, comprehension intact. She is an able medical historian. Concern during the admission was that her gait was notable for one person assist, and without walker she doesn't have a secure stance and is hesitant taking steps. She was seen by ___ who recommended a short rehab stay for her. Her seizure was likely in relation to the lowered dose and she is doing well on the higher dose. She had an EEG while in the hospital which did not show any events wore epileptic activity but the final report is still pending. She is compliant with medications and has no intercurrent illness that seemed to be contributing. We have increased her keppra back to 1500mg bid. transitional issues; follow up keppra level and final EEG read Medications on Admission: -amlodipine 2.5 mg daily -Trusopt 2 % Eye Drops 1 drop both eyes bid -Xalatan 0.005 % Eye Drops 1 drop both eyes qhs -Keppra 1000 mg/1500 mg -lisinopril 30 mg daily -simvastatin 20 mg daily -aspirin 325 mg daily -lactobacillus acidophilus 100 million cell capsule bid Discharge Medications: 1. Alendronate Sodium 70 mg PO QWED 2. Amlodipine 2.5 mg PO DAILY 3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 5. LeVETiracetam 1500 mg PO BID 6. Lisinopril 30 mg PO DAILY 7. Simvastatin 20 mg PO DAILY 8. Aspirin 325 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You were evaluated at the ___ for your complaint of seizures and decreased strength. While in the hospital, we assessed your strength which has improved over the course of 24 hours. We also increased your Keppra medication from 1000 mg in the morning and 1500 mg in the evening to 1500 mg twice a day. We also gave you an extra dose of Keppra to bring your levels to an appropriate level. Please continue the medications we have prescribed as written, and follow up with the appointments as listed below Followup Instructions: ___
19826668-DS-18	19,826,668	29,752,533	DS	18	2125-10-23 00:00:00	2125-10-23 15:24:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Lymph node biopsy Port placement ___ History of Present Illness: ___ w schizophrenia presents with abdominal pain. Was in USOH until about a week prior to admission when developed abd pain, which is LLQ and mid epigastric with distention, radiating also into "kidneys". Mild nausea, no vomiting. Pain is worse with eating, not positional, not exertional, not pleuritic. Denies f/c/cp/sob/d/rash/joint pain. Denies dysuria or urgency. Reports ___ years of baseline frequency. No HA, confusion, weakness, numbness, tingling, cough, rash. Endorses 6kg weight loss in last month, unintentional. No night sweats. Never had a colonoscopy. No breast masses or other LAD. No vaginal bleeding. No melena/BRBPR. Father with osteosarcoma and sister with brain tumor as below. Presented to ED, AVSS, LLQ tenderness, CT ordered which showed new metastatic malignancy of unknown primary. CBC/BMP as below. UA unremarkable. Given morphine and CTX for possibility of UTI, as well as IVF. She was informed of thought of malignancy. Admitted to medicine. Above interview performed with interpreter. ROS: positive or negative as above, otherwise negative in 12 systems Past Medical History: schizophrenia positive PPD Social History: ___ Family History: sister with GBM father died of osteosarcoma otherwise reviewed and non-contributory to current presentation Physical Exam: ============================== ADMISSION PHYSICAL EXAMINATION ============================== Constitutional: VS reviewed, NAD HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM without exudate CV: RRR no mrg Resp: CTAB GI: mildly ttp epigastrum and LLQ, s, nd, NABS GU: no foley, neg CVAT MSK: no obvious synovitis Ext: wwp, neg edema in BLEs Skin: no rash grossly visible Neuro: A&Ox3, ___ BUE/BLE, SILT BUE/BLE, CN II-XII intact Psych: normal affect, pleasant ============================== DISCHARGE PHYSICAL EXAMINATION ============================== Gen: Pleasant, speaking ___ and ___, somewhat tired appearing HEENT: No conjunctival pallor. No icterus. MMM. OP without any lesions. Pupils are pinpoint bilaterally and have been persistently. LYMPH: No cervical or supraclavicular lymphadenopathy CHEST: Normocardic, regular. Normal S1, S2. Port in R upper chest, tender to palpation and no surrounding erythema. LUNGS: Clear bilaterally. No use of accessory muscles or evidence of respiratory distress. ABD: Soft, non-tender, mildly distended. Normoactive bowel sounds. EXT: No lower extremity edema. Warm extremities. SKIN: No rashes/lesions, no petechiae/purpura or ecchymoses. NEURO: A&Ox3. No focal deficits. LINES: Port in right upper chest with tegaderm dressing Pertinent Results: ADMISSION RESULTS ___ 11:30PM BLOOD WBC-11.6* RBC-4.31 Hgb-12.7 Hct-38.4 MCV-89 MCH-29.5 MCHC-33.1 RDW-13.1 RDWSD-42.5 Plt ___ ___ 11:30PM BLOOD Neuts-80.0* Lymphs-8.6* Monos-5.4 Eos-4.7 Baso-0.9 Im ___ AbsNeut-9.27* AbsLymp-0.99* AbsMono-0.62 AbsEos-0.54 AbsBaso-0.10* ___ 11:30PM BLOOD Glucose-132* UreaN-16 Creat-0.6 Na-141 K-4.5 Cl-103 HCO3-23 AnGap-15 ___ 11:30PM BLOOD ALT-15 AST-18 LD(LDH)-402* AlkPhos-144* TotBili-0.2 ___ 11:30PM BLOOD Albumin-3.7 Calcium-9.1 Phos-4.1 Mg-1.9 UricAcd-4.6 ___ 11:21PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD* ___ 11:21PM URINE RBC-1 WBC-12* Bacteri-FEW* Yeast-NONE Epi-2 ___ CULTUREBlood Culture, Routine-PENDINGEMERGENCY WARD ___ CULTURE-FINALEMERGENCY WARD ========= PERTINENT INTERVAL RESULTS ___ 11:30PM BLOOD CEA-1.5 ___ 11:30PM BLOOD CA ___ wnl ___ PET CT Study IMPRESSION: 1. Extensive FDG avid lymphadenopathy involving the cervical, mediastinal, mesenteric, retroperitoneal and pelvic lymph node stations. The largest conglomerate is in the retroperitoneum, with an SUV max of 79.7. ___ 5. 2. Left-sided mildly FDG avid thyroid nodule for which a non emergent thyroid ultrasound is recommended. 3. Trace left pleural effusion. RECOMMENDATION(S): Non-emergent thyroid ultrasound. ___ TRANSTHORACIC ECHOCARDIOGRAM The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (3D LVEF = 59 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Mild pulmonary hypertension. IMPRESSION: Normal LV systolic function. No pathologic valvular flow identified. Mild pulmonary hypertension. CT ABD/PELVIS IMPRESSION: 1. Findings most likely represent neoplasm of unknown primary with hepatic metastases, extensive retroperitoneal lymphadenopathy including involvement of the left external iliac chain, encasement of the aorta, and invasion of the left psoas muscle, and enhancing soft tissue nodules adjacent and superior to the left iliacus muscle. Differential considerations include carcinoma, lymphoma, or a left lower extremity malignancy such as melanoma given asymmetric left pelvic lymphadenopathy. Recommend correlation for left lower extremity lesions including skin lesions. Lymphadenopathy would be amenable to percutaneous biopsy. 2. Small, round, well-circumscribed intermediate attenuation right renal lesion, possibly hemorrhagic or proteinaceous cyst. This could be further assessed with nonemergent renal ultrasound. RECOMMENDATION(S): 1. Malignancy of unknown primary with hepatic metastases, extensive retroperitoneal lymphadenopathy including involvement of the left external iliac chain, encasement of the aorta, and invasion of the left psoas muscle, and enhancing soft tissue nodules adjacent and superior to the left iliacus muscle. Differential considerations include carcinoma, lymphoma, or a left lower extremity malignancy such as melanoma given asymmetric left pelvic lymphadenopathy. Recommend correlation for left lower extremity lesions including skin lesions. Lymphadenopathy would be amenable to percutaneous biopsy. 2. Small, round, well-circumscribed intermediate attenuation right renal lesion, possibly hemorrhagic or proteinaceous cyst. This could be further assessed with nonemergent renal ultrasound. RENAL U/S IMPRESSION: Bilateral simple renal cysts measuring up to 4.2 cm in the left lower pole, otherwise normal renal ultrasound. CT Chest IMPRESSION: -Posterior paraesophageal mediastinal lymph node is the only pathologically enlarged lymph node in the chest. No other evidence of intrathoracic malignancy. -Retrocrural adenopathy does not extend above the diaphragm. -Thyroid abnormalities up to 2.2 cm should be evaluated by ultrasound. RECOMMENDATION(S): Ultrasound of the thyroid. MR LIVER IMPRESSION: 1. Multiple hepatic hemangiomas measuring up to 26 mm, as above. No evidence of hepatic metastatic disease. 2. Large primarily left periaortic retroperitoneal mass with closely adjacent bulky mesenteric root lymphadenopathy, partially imaged and more completely evaluated on recent CT abdomen and pelvis. Although nonspecific, MRI appearance is suggestive of lymphoma. ============================ DISCHARGE LABORATORY STUDIES ============================ ___ 12:00AM BLOOD WBC-14.2* RBC-3.44* Hgb-9.7* Hct-31.2* MCV-91 MCH-28.2 MCHC-31.1* RDW-14.1 RDWSD-46.2 Plt ___ ___ 12:00AM BLOOD Neuts-81* Bands-1 Lymphs-5* Monos-5 Eos-3 Baso-0 ___ Metas-5* Myelos-0 AbsNeut-11.64* AbsLymp-0.71* AbsMono-0.71 AbsEos-0.43 AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 12:00AM BLOOD Plt Smr-LOW* Plt ___ ___ 12:00AM BLOOD ___ PTT-27.5 ___ ___ 12:00AM BLOOD ___ ___ 12:00AM BLOOD ___ ___ 12:00AM BLOOD Glucose-70 UreaN-12 Creat-0.5 Na-143 K-4.3 Cl-103 HCO3-28 AnGap-12 ___ 12:00AM BLOOD ALT-15 AST-11 LD(LDH)-267* AlkPhos-147* TotBili-<0.2 ___ 12:00AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1 UricAcd-3.2 ___ 06:45AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 11:30PM BLOOD CEA-1.5 ___ 06:45AM BLOOD b2micro-2.7* ___ 06:20AM BLOOD HIV Ab-NEG ___ 06:20AM BLOOD HIV1 VL-NOT DETECT ___ 06:45AM BLOOD HBV VL-NOT DETECT ___ 06:45AM BLOOD HCV Ab-NEG Brief Hospital Course: Summary: =========== Ms. ___ is a ___ year-old woman with schizophrenia who presented with abdominal pain and decreased appetite and was found to have extensive lymphadenopathy on CT scan. Subsequent biopsy confirmed diffuse large B-cell lymphoma. She initiated her first cycle of CHOP chemotherapy on ___. ACUTE ISSUES: =============== # Diffuse Large B Cell Lymphoma: CHOP 21 Day Cycle, Cycle 1 Day 1 of ___. Discharged on ___, cycle day 12 Imaging on admission showed a large tumor burden in the retroperitoneal space. She underwent PET scan on ___ confirmed extensive retroperitoneal lymphadenopathy as well as cervical, mediastinal, mesenteric, and pelvic lymph node stations. Genetic analysis revealed she has BCL2 rearrangement on FISH but no BCL6 or MYC. She started CHOP chemotherapy cycle 1 on ___. She was given allopurinol ___ daily for tumor lysis syndrome prophylaxis. She was started on neupogen on ___, 24 hours following the completion of her chemotherapy infusion. Her nadir occurred on ___ and her neupogen was subsequently discontinued. On ___ a port was placed. She had split dose rituximab on ___ and ___ of 200mg and then 500mg, which was well tolerated. CHRONIC ISSUES: ================ # Schizophrenia: Her mood was stable throughout her admission, and she was able to understand and consent to every aspect of her care. She was continued on home clozapine and lorazepam. She was initially very reluctant to have a port placed, but with continued education from providers and family she consented to placement, which was uncomplicated. TRANSITIONAL ISSUES: ======================= # New Medications: [ ] Ranitidine for acid reflux [ ] Ativan 0.5mg PRN for nausea [ ] Docusate 100 mg BID for constipation Discharge WBC = 14.2 Discharge Hb = 9.7 Discharge Plt = 145 Discharge LDH = 267 [ ] Thyroid cyst: Per radiology did not appear to be urgent need as not suspicious. She will need follow up thyroid ultrasound as an outpatient. # CODE: Presumed Full # EMERGENCY CONTACT: ___ (Niece) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clozapine 300 mg PO QHS 2. LORazepam 0.5 mg PO QHS 3. Clozapine 12.5 mg PO QAM 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth Twice Daily Disp #60 Capsule Refills:0 2. LORazepam 0.5 mg PO Q8H:PRN Nausea RX lorazepam 0.5 mg 1 tablet(s) by mouth Every 8 hours as needed Disp #15 Tablet Refills:0 3. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 capsule(s) by mouth Twice daily Disp #60 Capsule Refills:0 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild RX acetaminophen 500 mg 1 tablet(s) by mouth Every 6 hours Disp #120 Tablet Refills:0 5. Clozapine 300 mg PO QHS RX clozapine 100 mg 3 tablet(s) by mouth Every evening Disp #90 Tablet Refills:0 6. Clozapine 12.5 mg PO QAM RX clozapine 12.5 mg 1 tablet(s) by mouth Every morning Disp #30 Tablet Refills:0 7. LORazepam 0.5 mg PO QHS RX lorazepam 0.5 mg 1 tab by mouth Every evening Disp #30 Tablet Refills:*0 Discharge Disposition: Home Facility: ___ Discharge Diagnosis: Primary Diagnosis: ------------------- Diffuse Large B Cell Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was our pleasure caring for you at ___ ___. WHY DID YOU COME TO THE HOSPITAL? You had abdominal pain, and a low appetite WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - A CT Scan showed lots of enlarged lymph nodes in your abdomen, concerning for cancer - You were diagnosed with diffuse large B-Cell lymphoma, which is a kind of cancer - You received chemotherapy for the lymphoma - You had a special IV put in your chest called a port WHAT SHOULD YOU DO WHEN YOU GET HOME - Please continue to take all of your medications. - You will follow up with your oncologist and continue chemotherapy sessions as an outpatient Thank you for allowing us to participate in your care! Best, Your ___ Care Team Followup Instructions: ___
19826668-DS-19	19,826,668	29,559,483	DS	19	2125-12-05 00:00:00	2125-12-05 16:01:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: admit with low grade fever, n/v/d Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with history of schizophrenia and newly diagnosed DLBCL. She presented with abdominal and back pain prompting CT consistent with extensive abdominal adenopathy. PET scan on ___ confirmed extensive retroperitoneal lymphadenopathy as well as FDG avid lymphadenopathy in cervical, mediastinal, mesenteric, and pelvic lymph node stations. Subsequent biopsy revealed diffuse large B-cell lymphoma; analysis on FISH showed BCL2 rearrangement, but no BCL6 or MYC. She was initiated on CHOP chemotherapy on ___. She has since completed 3C and presents from ED with low grade fever nausea vomiting and diarrhea. Past Medical History: TREATMENT HISTORY: ================== - ___, C1 D1 CHOP; no evidence for tumor lysis. Nadir supported by Neupogen. - ___, POC placed; Rituxan given in split doses on ___ and ___ of 200mg and then 500mg. Discharged back to her residence at the ___ on ___. - ___ Cycle of R-CHOP; given Neulasta the following day. PAST MEDICAL HISTORY: --DLBCL, as noted above --Schizophrenia, well controlled on medications. --Positive PPD Social History: ___ Family History: sister with GBM father died of osteosarcoma otherwise reviewed and non-contributory to current presentation Physical Exam: ADMISSION PHYSICAL EXAM: ========================= GEN: NAD fatigue appearing ___ 1620 Temp: 98.2 PO HR: 72 RR: 18 O2 sat: 95% O2 delivery: ___ HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary LAD CV: Regular, normal S1 and S2 no S3, S4, or murmurs PULM: Clear to auscultation bilaterally ABD: BS+, soft, non-tender, non-distended, no masses, no hepatosplenomegaly LIMBS: No edema, no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Grossly nonfocal, alert and oriented DISCHARGE PHYSICAL EXAM: =========================== ___ 0819 Temp: 98.5 PO BP: 119/76 HR: 95 RR: 16 O2 sat: 96% O2 delivery: Ra GEN: NAD fatigue appearing HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary LAD CV: Regular, normal S1 and S2 no S3, S4, or murmurs PULM: clear to auscultation bilaterally ABD: hypoactive BS, soft, non-tender/non-distended, no masses or HSM LIMBS: No edema or inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Right nasal labial fold flattening. A/O x3. Overall, grossly non-focal, appropriate. CN II-XII intact. Strength and sensation intact. Pertinent Results: ADMISSION LABS: =============== ___ 11:40AM BLOOD WBC-84.9* RBC-3.72* Hgb-11.2 Hct-34.0 MCV-91 MCH-30.1 MCHC-32.9 RDW-17.5* RDWSD-57.5* Plt ___ ___ 11:40AM BLOOD Neuts-92* Bands-1 Lymphs-5* Monos-2* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-78.96* AbsLymp-4.25* AbsMono-1.70* AbsEos-0.00* AbsBaso-0.00* ___ 11:40AM BLOOD Glucose-72 UreaN-16 Creat-0.6 Na-144 K-3.5 Cl-105 HCO3-24 AnGap-15 ___ 11:40AM BLOOD ALT-19 AST-18 AlkPhos-88 TotBili-0.5 ___ 11:40AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.9 Mg-2.0 DISCHARGE LABS: =============== ___ 12:00AM BLOOD WBC-12.5* RBC-2.97* Hgb-8.9* Hct-27.5* MCV-93 MCH-30.0 MCHC-32.4 RDW-18.6* RDWSD-61.3* Plt ___ ___ 12:00AM BLOOD Neuts-79.5* Lymphs-4.2* Monos-9.8 Eos-1.3 Baso-0.6 Im ___ AbsNeut-9.93* AbsLymp-0.53* AbsMono-1.22* AbsEos-0.16 AbsBaso-0.08 ___ 12:00AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+* Macrocy-1+* Microcy-NORMAL Polychr-1+* Ovalocy-1+* Schisto-OCCASIONAL Tear Dr-OCCASIONAL ___ 12:00AM BLOOD Plt ___ ___ 12:00AM BLOOD Glucose-112* UreaN-11 Creat-0.6 Na-140 K-4.1 Cl-98 HCO3-25 AnGap-17 ___ 12:00AM BLOOD ALT-18 AST-13 LD(LDH)-193 AlkPhos-106* TotBili-0.2 ___ 12:00AM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.5 Mg-1.9 ___ 02:36PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:27PM BLOOD cTropnT-<0.01 ___ 11:40AM BLOOD cTropnT-<0.01 ___ 11:40AM BLOOD Lipase-34 ___ 12:24AM BLOOD Triglyc-71 HDL-62 CHOL/HD-2.5 LDLcalc-76 ___ 12:24AM BLOOD %HbA1c-5.1 eAG-100 MICROBIOLOGY: ============== URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S IMAGING: ========== CTA HEAD ___: IMPRESSION: No significant abnormalities on CT of the head without contrast. No significant abnormalities on CT angiography of the head and neck. Other findings as described above. MR HEAD ___: FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction findings consistent with minimal chronic small vessel ischemic changes. Mild brain parenchymal atrophy, most prominent at the sylvian fissures. Intracranial vascular flow voids are preserved. Clear paranasal sinuses. Trace opacification bilateral mastoids. IMPRESSION: No acute findings CXR ___: IMPRESSION: Compared to chest radiographs ___. Small opacity at the lateral periphery of the left lower lobe is new could be a small region of infection, infarction, or atelectasis. Pleural effusions are small if any. Upper lungs clear. Heart size normal. Right central venous infusion catheter ends in the region of the superior cavoatrial junction. CTA CHEST ___: FINDINGS: HEART AND VASCULATURE: Slightly motion limited exam particularly at the lung bases. Pulmonary vasculature is well opacified to the segmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. A posterior paraesophageal lymph node that was previously enlarged now measures 5 mm, within normal limits (04:50). Right chest wall port device has leads terminating in the right atrium. PLEURAL SPACES: Small left pleural effusion. No pneumothorax. LUNGS/AIRWAYS: Mild compressive atelectasis at the left base. Lungs are otherwise clear without masses or areas of parenchymal opacification. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Thyroid gland is heterogeneous and enlarged on the left side hypoenhancing nodule measures up to 1.5 cm, not significant changed from prior. There is also calcifications in the left thyroid lobe. ABDOMEN: Three hypodense lesions in the liver measuring up to 1.9 cm (4:112, 4:105, 4:101) are stable from prior exams and not FDG avid on recent PET imaging. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: No evidence of pulmonary embolism or acute aortic abnormality. No evidence of septic emboli. Previously seen enlarged posterior paraesophageal lymph node is now within normal limits. Small left pleural effusion. Brief Hospital Course: ASSESSMENT AND PLAN: Ms. ___ is a ___ year-old female with history of schizophrenia who presented with abdominal pain with extensive lymphadenopathy on CT scan and biopsy confirming diffuse large B-cell lymphoma, currently s/p 3C of R-CHOP admitted with nausea, vomiting, and diarrhea. She was noted for new neurological findings ___ and +enterococcus UTI. ACUTE ISSUES: ============== #Confusion/Slurred speech: She was noted for acute onset slurred speech and confusion on ___, prompting a stat code stroke and neurology consultation. CTA head and neck negative for infarct, hemorrhage or masses. Cardiac enzymes negative, hgb A1C and lipid panel WNL. Infectious work up consistent with enterococcus UTI (see problem #2) which is most likely cause of this acute change in her mental status. Other differential includes TIA, infection, and/or medication related. Neurology team added that though her imaging was unrevealing, she may have had a small infarct that was not evident on imaging; therefore, they did recommend ASA and she was discharged on this medication. ASA may need to be held inter-cycle during her nadir. She has an appointment with neurologist, Dr. ___, on ___. #Enterococcus UTI: #Fever/Neutrapenia: Prior to admission, patient was noted to have low grade fevers. In addition during her hospitalization, she was noted to be borderline neutrapenic (since resolved). In the context of AMS workup as above, she was found to have enterococcus UTI. Albeit she did not have other UTI symptoms (dysuria, urgency, frequency, hematuria), the changes in mental status could have been a possible clinical manifestation. Sensitive to ampicillin and non-neutropenic at the time of urine culture results; therefore, initiated on amoxicillin [___] first for treatment but changed to vancomycin given nadir as well as possible PNA that was reported on CXR. Follow up imaging with CTA Chest did not show evidence of a pulmonary infection but she continued on vancomycin [___] as she was neutrapenic at this time and recently completed a 7D course for complicated UTI on ___. Repeat urine culture on ___ showed no growth. She currently has no mental status changes as well as other UTI-related symptoms. Monitor outpatient for reoccurrence of symptoms #Nausea/Vomiting/Diarrhea (resolved): #Emesis (resolved): #Low grade fevers (resolved): Suspect likely viral gastroenteritis. Overall, her symptoms have resolved. Infectious workup was unrevealing except as noted above. We did not send stool studies as she did not have any episodes of diarrhea during her hospitalization. Continue supportive care as needed with antiemetics. She is able to maintain oral hydration adequately. #Constipation: She now have stooled in the past two days. She continues on bowel regimen at discharge. She has no abdominal pain. CHRONIC ISSUES: ================ #Diffuse Large B Cell Lymphoma, germinal center phenotype: Goal of treatment is cure with plan for 6 cycles of therapy. Plan for restaging with count recovery after this cycle. Patient is s/p 3C of R-CHOP (C3 given outpatient ___ as well as Neulasta on ___. At discharge (___), she is D+14 of her regimen. She completed her prednisone in-house per CHOP regimen on ___. She has an Echocardiogram and CT torso scheduled on ___ and then is due for her next cycle of R-CHOP (C4) on ___. She was started on acyclovir for infectious prophylaxis. #History + PPD: Apparently was seen by PCP ~ ___ years ago at time of transferring to ___. By report, patient did receive the BCG vaccine but the response was increased more than expected at that time. No symptoms of TB. Chest x-ray and chest CT do not show any abnormalities. However, given diagnosis of lymphoma and current treatment, she was initiated on INH and B6 for prevention of reactivation of latent TB. #Schizophrenia/Agitation: Normally, she is well controlled on current medications but skipped dosing on ___ and ___ due to GI symptoms as above. She has good understanding of her care and treatment. She was noted to be agitated on ___ which was most likely multifactorial in setting of acute infection and missed home medications due to GI upset. At this time, she was managed with as needed Seroquel. Since ___, she has been back to her baseline and has had no acute exacerbations. She continues on Clozapine (12.5mg PO in the morning and 300mg PO at bedtime). She only takes Olanzapine on her steroid days per her outpatient team. Most recent Qtc monitoring was stable (423). CORE MEASURES: ============== #Access: POC #Contact: ___ #Disposition: Discharged ___ to the ___. She has an appointment on ___ for imaging (ECHO/CT TORSO) and will see her primary team on ___ for the next cycle of her chemotherapy (C4 of R-CHOP). #Code Status: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clozapine 300 mg PO QHS 2. Clozapine 12.5 mg PO QAM 3. Isoniazid ___ mg PO DAILY 4. LORazepam 0.5 mg PO QHS:PRN insomnia 5. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS 6. Ondansetron 8 mg PO Q8H:PRN nausea 7. PredniSONE 100 mg PO DAILY 8. Promethazine 12.5 mg PO Q8H:PRN nausea 9. Ranitidine 150 mg PO BID 10. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Aspirin 81 mg PO DAILY 3. Clozapine 300 mg PO QHS 4. Clozapine 12.5 mg PO QAM 5. Docusate Sodium 100 mg PO BID HOLD WITH DIARRHEA 6. Isoniazid ___ mg PO DAILY 7. LORazepam 0.5 mg PO QHS:PRN insomnia 8. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS ONLY ON DAYS OF PREDNISONE (PER YOUR ___. ___ 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Promethazine 12.5 mg PO Q8H:PRN nausea 11. Pyridoxine 50 mg PO DAILY 12. Ranitidine 150 mg PO BID 13. Senna 8.6 mg PO BID HOLD WITH DIARRHEA Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ==================== #ENTEROCOCCUS UTI #VIRAL GASTROENTERITIS SECONDARY DIAGNOSIS: ====================== #DLBCL #SCHIZOPHRENIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted due to nausea, vomiting, and diarrhea. This was likely due to a viral infection and improved with time. You were also found have altered mental status and a urinary tract infection. You were treated with intravenous antibiotics and your symptoms have resolved. You will follow up with the neurology team outpatient. You will be discharged home and follow up in the clinic as stated below. It was a pleasure taking care of you. Followup Instructions: ___
19826668-DS-23	19,826,668	25,159,781	DS	23	2126-02-22 00:00:00	2126-02-22 18:24:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: malaise, urinary incontinence Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ w/ schizophrenia, DLBCL s/p C6D1 RCHOP ___ who p/w weakness x2 days. She was seen in ED yesterday for leg swelling. Her oncologist was consulted, felt likely lymphedema, patient discharged home. Per ED staff, she returned to ___ today with increasing fatigue. No back pain or focal neuro deficit on exam. Of note she has a h/o catatonia, over sedation from lorazepam, and lethargy and encephalopathy during chemotherapy. In ED, UA c/w UTI. VSS. Started on CTX. NCHCT non acute. On arrival to ___, pt denied any fatigue. States she feels her usual self aside from the ___ which is unchanged for several weeks. She denied any F/C, no n/v, no abd pain, no dysuria, no increased urinary frequency or incontinence. I called her nurse from ___ this evening who knows the patient well to obtain further collateral. She states pt had increased edema recently but the reason they sent her in this am to the ED was because she was "extremely sedated, unarousable" "very difficult to arouse," and this was unusual for her. They also noted she had urinary incontinence and this out of the norm for her. Nurse also noted that over the past month pt had been more withdrawn, "her hygiene is going downhill," "does not answer our questions," and noted she is always denying symptoms. Even though she sees psychiatry, they feel she under-reports her symptoms which may be interfering with her care. When she "is very obviously nauseas, she denies nausea." She received her lorazepam last night which she gets standing and no other sedating meds. NO changes to her meds recently, including clozapine 12.5 mg in am and 300 qhs and 0.5 ativan qhs. They did not find any other deranged vitals on her. Past Medical History: As per admitting MD: - ___, C1 D1 CHOP; no evidence for tumor lysis. Nadir supported by Neupogen. - ___, POC placed; Rituxan given in split doses on ___ and ___ of 200mg and then 500mg. Discharged back to her residence at the ___ on ___. - ___ Cycle of R-CHOP; given Neulasta the following day. - ___, C3 D1 RCHOP - ___ - ___, Admitted with fever, diarrhea, vomiting. Felt to be viral illness. Also noted for UTI. Kept through nadir. - ___, C4 D1 RCHOP PAST MEDICAL HISTORY (Per OMR, reviewed): -Schizophrenia, well controlled on medications. -LTBI Social History: ___ Family History: As per admitting MD: -Sister with GBM -Father died of osteosarcoma Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITAL SIGNS: ___ Temp: 97.2 PO BP: 124/74 HR: 97 RR: 18 O2 sat: 99% O2 delivery: RA General: NAD, Resting in bed comfortably, watching TV, awake and interactive HEENT: MMM, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs LIMBS: WWP, +b/l non-pitting ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: CN III-XII intact, strength b/l ___ intact PSYCH: Thought process logical, linear, future oriented, denied any AH/VH ACCESS: Chest port site intact w/o overlying erythema, accessed and dressing C/D/I DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 822) Temp: 97.6 (Tm 97.8), BP: 121/75 (94-127/58-76), HR: 94 (80-101), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: RA General: NAD, sitting in chair HEENT: MMM CV: RRR, nl S1S2, no murmurs/rubs/gallops PULM: CTAB ABD: BS+, soft, nondistended, nontender, No CVA tenderness LIMBS: WWP, +b/l pitting ___, no tremors SKIN: No notable rashes on trunk nor extremities NEURO: Alert and oriented x3. Moving all extremities PSYCH: Thought process logical, linear, future oriented, denied any AH/VH ACCESS: Chest port site intact w/o overlying erythema, accessed and dressing C/D/I Pertinent Results: ADMISSION LABS: =============== ___ 04:04PM BLOOD WBC-3.2* RBC-2.84* Hgb-9.1* Hct-27.8* MCV-98 MCH-32.0 MCHC-32.7 RDW-15.0 RDWSD-53.8* Plt ___ ___ 04:04PM BLOOD Neuts-57.1 Lymphs-18.0* Monos-19.9* Eos-2.5 Baso-2.2* Im ___ AbsNeut-1.81 AbsLymp-0.57* AbsMono-0.63 AbsEos-0.08 AbsBaso-0.07 ___ 04:04PM BLOOD Plt ___ ___ 04:04PM BLOOD Glucose-104* UreaN-9 Creat-0.5 Na-145 K-3.9 Cl-108 HCO3-26 AnGap-11 ___ 04:04PM BLOOD LD(LDH)-149 ___ 04:04PM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9 RELEVANT LABS: ============= ___ 04:39PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 04:39PM URINE Blood-TR* Nitrite-POS* Protein-30* Glucose-NEG Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* ___ 04:39PM URINE RBC-11* WBC->182* Bacteri-FEW* Yeast-NONE Epi-<1 TransE-1 ___ 04:39PM URINE Mucous-OCC* MICROBIOLOGY: ============= URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS: ============== Follow up clozapine level: currently pending IMAGING/STUDIES: ================ CXR (___) No acute cardiopulmonary process Noncontrast Head CT (___) No evidence of acute intracranial abnormality. No abnormal enhancement seen on postcontrast images. CT Chest (___) No signs of disease recurrence are seen. CTAP (___) 1. Stable, treated retroperitoneal adenopathy, now measuring 1.9 cm, previously 1.8 cm. No new adenopathy within the abdomen or pelvis. 2. Diffuse mild bladder wall thickening with surrounding fat stranding may be compatible with cystitis. Echo (___) The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is 60%. There is no resting left ventricular outflow tract gradient. There is Grade I diastolic dysfunction. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion Brief Hospital Course: Ms. ___ is a ___ woman with schizophrenia on clozapine, DLBCL s/p C6D1 RCHOP ___ who presented with worsening fatigue and per group home report found to be "unarousable," also with worsening urinary incontinence. Found to have UTI with UCx growing pan-sensitive klebsiella, was started on IV ceftriaxone, with subsequently improved mental status. Was transitioned to PO macrobid on discharge to complete a 7 day total course of antibiotics. ACUTE ISSUES ================================== # Malaise/toxic metabolic encephalopathy # UTI - Initially presented with worsening altered mental status, with collateral from ___ home RN noting acute episode of unresponsiveness prior to admission, also with worsening urinary incontinence. Was found to have pan-sensitive klebsiella UTI. AMS was likely multifactorial, with UTI, also has a known propensity for lethargy/encephalopathic with chemotherapy. There were also concerns with polypharmacy given her home meds of ativan and clozapine. She was started on IV CTX for empiric treatment of UTI with improvement of her mental status back to baseline, discharged on macrobid for 7 day total course to be completed on. Psychiatry was consulted and recommended decreasing clozapine to only 300mg qhs, stopping her home clozapine 12.5mg PO QAM, and decreasing ativan from 0.5 to 0.25mg QHS:PRN. CHRONIC ISSUES ================================== # DLBCL - History of DLBCL s/p C6D1 RCHOP ___. She completed 6C R-CHOP with neupogen. She was continued on her home acyclovir. She had a repeat staging CT chest/abdomen/pelvis which showed no signs of disease recurrence in the torso and stable, treated retroperitoneal adenopathy, now measuring 1.9 cm, previously 1.8 cm. No new adenopathy within the abdomen or pelvis. Echo showed normal LV function with a EF of 60%. New Grade I diastolic dysfunction. No other abnormality. # Prolonged QTc - QTc on admission was prolonged on 498 msec and so was kept on telemetry showed no events. A repeat QTc showed QTc 456. Her home antiemetics were held in the setting of her prolonged QTc, and per psych recommendations, her home clozapine dose was decreased from 12.5mg in AM/300mg ___ to 300mg ___ only. # Schizophrenia (c/b by catatonia) - She seems to be compensated but pt's SNF nursing noted progressive withdrawn personality over the past month with worse hygiene, less eager to answer questions, but otherwise pleasant. She is very reluctant to complain of any symptoms per nursing report. Per above in consultation with psychiatry, morning clozapine dose of 12.5mg was held and discontinued on discharege and decreasing her nightly ativan to 0.25mg PRN insomnia. Repeat clozapine level was pending at discharge, to be followed with outpatient titration of home medications by outpatient psychiatrist ___ with discharge appointment arranged for ___. # Latent TB - Continued on INH 300mg QD + b6 # Lower extremity edema - With non-pitting bilateral lower extremity edema, ___ ___ revealed no DVT. Echo showing some mild Grade I diastolic dysfunction EF 60%. TRANSITIONAL ISSUES: ================== [ ] NEW/CHANGED MEDICATIONS - Started macrobid ___ BID to be continued through ___ - Discontinued Clozapine 12.5mg qAM given sedation/AMS prior to admission in consultation with psychiatry - Lorazepam decreased from 0.5mg qPM to 0.25mg QHS:PRN given sedation/AMS prior to admission [ ] Clozapine level pending at discharge to be followed by outpatient psychiatrist with titration of clozapine as indicated [ ] Consider outpatient cardiology referral by PCP if indicated given grade 1 diastolic dysfunction ___ STATUS: Full ___, presumed CONTACT: ___ (___) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Aspirin 81 mg PO DAILY 3. Clozapine 12.5 mg PO QAM 4. Clozapine 300 mg PO QHS 5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 6. Isoniazid ___ mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Promethazine 12.5 mg PO Q8H:PRN nausea 9. Pyridoxine 100 mg PO DAILY 10. Ranitidine 150 mg PO BID 11. Senna 8.6 mg PO BID:PRN Constipation - Second Line 12. LORazepam 0.5 mg PO QHS Discharge Medications: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 4 Days RX nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice a day Disp #8 Capsule Refills:0 2. LORazepam 0.25 mg PO QHS:PRN insomnia RX lorazepam [Ativan] 0.5 mg 0.5 (One half) by mouth QHS:PRN Disp #30 Tablet Refills:0 3. Acyclovir 400 mg PO Q12H RX acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:1 4. Aspirin 81 mg PO DAILY 5. Clozapine 300 mg PO QHS 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 7. Isoniazid ___ mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Pyridoxine 100 mg PO DAILY 10. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:1 11. Senna 8.6 mg PO BID:PRN Constipation - Second Line Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY - Urinary tract infection SECONDARY - DLBCL - completed post R-CHOP CTAP - Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. Why did you come to the hospital? - You were found to be more tired than usual and you had increasing urination What happened during your hospitalization? - You were found to have a UTI and you were treated with IV antibiotics and discharged on an oral antibiotic What should you do when you leave the hospital? - Continue to take all of your medications as prescribed, particularly your new antibiotic macrobid - Follow-up with your PCP ___ 1 week - Please keep all of your other scheduled health care appointments as listed below. Sincerely, Your ___ Care Team Followup Instructions: ___
19826668-DS-28	19,826,668	29,472,357	DS	28	2126-07-02 00:00:00	2126-07-02 14:27:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: kyphoplasty History of Present Illness: ___ ___ female with schizophrenia, diffuse large B-cell lymphoma s/p 6 cycles of R-CHOP, history of positive PPD, who presented with 4 days of low back pain. History was obtained using ___ iPad interpreter. Starting 4 days ago she began having new low back pain. She does not recall what she was doing at onset, but she denies trauma or falls. She presented to the ___ ED on ___ with back pain though no imaging was done at that time and was discharged home with lidocaine patch. She returned to the ED early this morning with ongoing pain and difficulty ambulating due to pain. She underwent CT abdomen/pelvis that showed acute compression fracture of T11 vertebral body with soft tissue swelling, but no other acute findings in the abdomen/pelvis. MRI spine showed T11 acute fracture with no evidence of cord compression. She was evaluated by neuro/spine in the ED who felt increased T8 uptake was concerning for possible malignancy. In the ED, she got IV Tylenol 1g, oxycodone 2.5mg and her home medications. Foley was placed there due to having 250-300cc on PVR. On arrival to the floor, she reports ___ pain that is intermittent in her low back. She denies numbness, tingling, or focal weakness. She denies incontinence or constipation (last bowel movement 1 day ago). She is asking for the Foley to be removed. She has been having difficulty ambulating due to the pain. The pain worsens with changing positions, ambulating, sitting. She was taking Tylenol twice daily without improvement. She denies fevers, night sweats, unintentional weight changes, dyspnea, nausea/vomiting, dizziness, lightheadedness. She was recently hospitalized from ___ - ___ for neutropenia worsening on clozapine, transferred from Deac 4. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Schizophrenia DLCBL Positive PPD No prior surgeries per pt Oncologic Treatment History; - ___, C1 D1 CHOP; no evidence for tumor lysis. Nadir supported by Neupogen. - ___, POC placed; Rituxan given in split doses on ___ and ___ of 200mg and then 500mg. Discharged back to her residence at the ___ on ___. - ___ Cycle of R-CHOP; given Neulasta the following day. - ___, C3 D1 RCHOP - ___ - ___, Admitted with fever, diarrhea, vomiting. Felt to be viral illness. Also noted for UTI. Kept through nadir. - ___, CT of the chest, abdomen and pelvis shows significant improvement in the retroperitoneal and pelvic adenopathy. - ___, C4 D1 RCHOP - ___ - ___, Admitted with vomiting, diarrhea and decreased oral intake; not able to be cared for at ___. Noted for altered mental status with negative work up. - ___, C5 D1 RCHOP - ___ - ___, Admitted for toxicity management after R-CHOP due to previous admissions. Had episode of lethargy and inattention which resolved without intervention; unclear etiology. - ___, C6 D1 RCHOP with admission for toxicity management. Recently admitted for psych decompensation, found to have neutropenia from clozapine and now stabilized on Risperdal long acting depot Social History: ___ Family History: Both parents deceased -Sister with brain tumor(GBM) at age ___ -Father died of osteosarcoma at age ___ -Mother died of heart disease Physical Exam: ADMISSION PHYSICAL EXAM VITALS: T 98.4F, BP 120/70, HR 68, RR 18, 97% on room air GENERAL: Alert and in no apparent distress, sitting in bed, comfortable, conversant EYES: Anicteric ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Moist mucus membranes. CV: Heart regular, no murmur, no S3, no S4. 2+ radial pulses bilaterally. No edema. RESP: Lungs clear to auscultation with good air movement bilaterally except for faint crackles at right base. Breathing is non-labored on room air. GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation, Foley draining yellow non-bloody urine MSK: Moves all extremities, tender to palpation over low back at mid-line and bilaterally SKIN: No rashes or ulcerations noted. Right chest port is clean, dry, without drainage/erythema/induration/tenderness. NEURO: Alert, oriented x3, face symmetric, speech fluent, ___ strength in all 4 extremities with intact sensation to light touch throughout PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM VS: Pertinent Results: ADMISSION LABS: ___ 10:51AM BLOOD Neuts-77.3* Lymphs-8.5* Monos-11.8 Eos-1.3 Baso-0.7 Im ___ AbsNeut-5.92 AbsLymp-0.65* AbsMono-0.90* AbsEos-0.10 AbsBaso-0.05 ___ 10:51AM BLOOD WBC-7.7 RBC-3.71* Hgb-10.6* Hct-32.1* MCV-87 MCH-28.6 MCHC-33.0 RDW-15.9* RDWSD-50.4* Plt ___ ___ 10:51AM BLOOD Plt ___ ___ 06:00AM BLOOD ___ ___ 10:51AM BLOOD Glucose-117* UreaN-13 Creat-0.6 Na-142 K-4.3 Cl-103 HCO3-26 AnGap-13 ___ 10:51AM BLOOD ALT-21 AST-13 AlkPhos-96 TotBili-0.5 ___ 10:51AM BLOOD Albumin-3.9 Calcium-9.4 Phos-4.3 Mg-1.9 IMAGING - CTAP ___: 1. Acute appearing compression fracture of the T11 vertebral body with prevertebral soft tissue swelling. No retropulsion. 2. No acute findings in the abdomen or pelvis. 3. Trace bilateral pleural effusions. - MRI spine ___: 1. Acute compression fracture of the T11 vertebral body with approximately 20% loss of height and approximately 2 mm of retropulsion of the posterior cortex resulting in mild spinal canal narrowing at this level. 2. No additional fractures are evident. 3. Multilevel multifactorial cervical spondylosis as described above, most pronounced at C5-C6 and C6-C7 with mild to moderate spinal canal narrowing. 4. No evidence of spinal cord edema. - ___ CTA head/neck wet read: CT head without contrast: No acute intracranial process. CTA head and neck: No vascular abnormalities are noted in the circle ___ and principal intracranial branches. Mild bilateral cavernous carotid artery calcifications are noted. No vascular abnormalities are noted of bilateral cervical carotid arteries and vertebral arteries. - LENIS ___: No evidence of deep venous thrombosis in the right or left lower extremity veins. Discharge Labs ___ 06:00AM BLOOD WBC-4.1 RBC-3.52* Hgb-9.9* Hct-31.0* MCV-88 MCH-28.1 MCHC-31.9* RDW-16.3* RDWSD-52.7* Plt ___ ___ 06:00AM BLOOD Glucose-90 UreaN-29* Creat-0.7 Na-139 K-4.6 Cl-99 HCO3-25 AnGap-15 Brief Hospital Course: ___ is a ___ hx DLBCL s/p 6c RCHOP, schizophrenia admitted with T11 compression fracture s/p kyphoplasty, with hospital course c/b ___ edema. # Acute T11 Compression Fracture: CTAP on admission with acute compression fracture of T11. Neurologic exam was reassuring. F/U MRI demonstrated no cord compression or signal. She underwent a kyphoplasty on ___ and subsequently had improvement in her back pain. She was treated with acetaminophen, lidocaine, cyclobenzaprine, and oxycodone for her pain. She was cleared for home discharge by ___. By day of discharge she was walking independently, with well controlled pain, and with normal neurologic exam. She was prescribed cyclobenzaprine 10 mg qhs, and advised to take ibuprofen 600 mg opo q6 hours prn and oxycodone 5 mg every 4 hours prn for breakthrough pain. By the end of her hospital stay, she was only requiring oxycodone 2x/day. She was discharged with 20 tablets of oxycodone, and advised to use them sparingly. # B/L ___ Edema: Patient developed lower extremity edema in final days of her hospital course. LENIS negative for DVT. She had no PND or orthopnea. Last TTE in ___ with normal EF, no WMA, normal valvular function, although PASP was borderline. Note that her CTAP from admission had small bilateral pleural effusions. She was started on furosemide with only mild improvement in her ___ edema. She was discharged with a furosemide prescription of 20 mg daily for the next 3 days, although it appears that the most important intervention for her edema is compression stockings or ACE bandages, and she agreed to this only on discharge. PCP can consider repeat ECHO but she does not appear to have other signs or symptoms of decompensated heart failure. # Facial Droop: Noted mid-hospitalization after change in RN/MD staff. It was unclear if this was acute, as did not match prior documented exams. Last known normal was outside intervention window. NIHSS 1. CTA head and neck were unremarkable, as was remainder of neurologic exam. Neurology consulted who recommended routine follow-up and secondary prevention. Home aspirin continued. # Schizophrenia: Continued home risperidone. Next IM dose due ___ # Insomnia: Continued home ramelteon and mirtazapine. # GERD: Continued home ranitidine. # DLBCL: In apparent remission following 6 cycles RCHOP ___. Continued home prophylactic acyclovir # Latent TB Infection: Pt was started on INH in ___ for projected 9mth time course but only completed 6mths prior to LFTs raising to 5x upper limit of normal. Per NSG, there is no concern for pathologic fracture - outpt f/u recommended for positive PPD s/p 6mths of INH # Incidental Findings - Enlarged left thyroid lobe with a dominant nodule measuring up to 3 cm noted on CTA neck. Will need outpatient thyroid US follow-up with ultrasound. Time spent coordinating discharge > 30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO DAILY 2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 3. Acyclovir 400 mg PO Q12H 4. Aspirin 81 mg PO DAILY 5. Mirtazapine 15 mg PO QHS 6. Ramelteon 8 mg PO QHS:PRN insomnia 7. Ranitidine 150 mg PO BID 8. RisperiDONE 4 mg PO QHS psychosis 9. RisperiDONE Long Acting Injection 25 mg IM EVERY 2 WEEKS (FR) Schizophrenia 10. Senna 8.6 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QPM Discharge Disposition: Extended Care Discharge Diagnosis: Compression fractures Lower extremity swelling Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with back pain and we found that you had compression fractures as the cause. You had a procedure called a kyphoplasty, and your back pain has come down considerably. You can take cyclobenzaprine at night for the next two weeks, and during the day, you can use ibuprofen and oxycodone as needed for pain. Oxycodone can cause constipation so please take stool softeners to make sure this does not happen. You have marked edema (swelling) in both your legs. It is very important to wear stockings daily and to keep your legs elevated. Please take Lasix in the morning for the next three days. If your swelling does not improve with stockings, please have the ___ staff wrap an ace bandage around the legs so that the fluid will be reabsorbed. We recommend that Dr ___ ___ an ultrasound of your thyroid gland to followup on what appears to be a cyst on your thyroid gland. Followup Instructions: ___
19826828-DS-19	19,826,828	25,882,399	DS	19	2178-01-14 00:00:00	2178-01-17 11:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Duragesic Attending: ___ Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with PMH of bilateral pulmonary embolism who presented to OSH with chest pain and worsening SOB who was found to have large pulmonary emboli. With respect to patient's previous pulmonary embolism, he was treated with 6 months of anticoagulation with Coumadin and workup for genetic component were negative. Patient reports that 4 days prior to admission to OSH he had worsneing shortness of breath and could no longer climb the stairs to his second floor apartment and started staying with his brother on the first floor. On day of admission, the patient developed shortness of breath with minimal exertion so he called EMS and was taken to an OSH. At the OSH, patient's troponin was elevated to 0.12 and BNP was also elevated. They were concerned for ACS and gave him Lovenox, Plavis, and atorvastatin and transferred him to ___ for cardiac catheterization. In the ___ ED, initial vital signs were afebrile, 92, 120/77, 16, and 94% on 3 L. Patient reported current symptoms were similar to his prior pulmonary embolism. Because of this he underwent CTA chest which showed larged bilateral pulmonary emboli. He was started on a heparin gtt and given morphine for pain. On arrival to the MICU, patient continued to complain of chest pain and also noted mild abdominal pain with distension and bloating. Patient also had thirst and dizziness on standing. In the MICU, patient was continued on heparin gtt. Past Medical History: - Pulmonary embolism in ___. Coumadin for 6 months. - Workup for genetic etiologies: * Factor V Leiden mutation not detected * Prothrombin G___ mutation not detected * ATIII level WNL * Protein C and S activity WNL * Lupus anticoagulant negative * ___: 8.7 * ___: 5.2 * ___ I antibodies IgG/IgM/IgA ___ * Homocysteine 7.2 umol/L ___ umol/L) - Hypertension - Benign prostatic hypertrophy - Chronic back pain - Depression - Opiate abuse s/p inpatient detoxification in ___ Social History: ___ Family History: Grandmother had problem with "clots" Mother and grandfather died at an early age from some sort of heart problems. Physical Exam: ADMISSION EXAM Vitals: 97.9, 91, 123/83, 17, 93% RA General: ___ male in no distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP at 8 cm, no LAD, lipoma posteriorly Lungs: Poor air movement, CTAB, no wheezes/rales/rhonchi CV: RRR, nl S1/S2, no MRG Abdomen: Soft, diffusely tender, distended, no rebound/guarding, normoactive bowel sounds GU: No Foley Ext: Warm, ___, no cyanosis/clubbing/edema, 1+ pulses Neuro: CN ___ grossly intact, motor function grossly normal DISCHARGE EXAM Vitals: 97.8, 106, 100/68, 20, 93% RA General: ___ male in no distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated Lungs: CTAB, no wheezes/rales/rhonchi CV: RRR, nl S1/S2, no MRG Abdomen: Soft, NTND, normoactive bowel sounds GU: No Foley Ext: Warm, ___, no cyanosis/clubbing/edema, 1+ pulses Neuro: CN ___ grossly intact Pertinent Results: ADMISSION LABS ___ 05:30PM BLOOD ___ ___ Plt ___ ___ 05:30PM BLOOD ___ ___ ___ 03:30AM BLOOD ___ ___ ___ 05:30PM BLOOD ___ ___ ___ 05:45PM BLOOD ___ DISCHARGE LABS ___ 06:00AM BLOOD ___ ___ Plt ___ ___ 06:00AM BLOOD ___ ___ ___ 06:00AM BLOOD ___ ___ ___ 06:00AM BLOOD ___ MICROBIOLOGY: Blood cultures NEGATIVE IMAGING TTE (___): The left atrium is mildly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF=55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] The main pulmonary artery is dilated. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Moderately dilated right ventricular cavity with moderate global free wall hypokinesis and pressure/volume overload. Severe pulmonary artery systolic hypertension. Small pericardial effusion with no echocardiographic signs of tamponade. Compared to the study on ___, the right ventricle is more dilated and hypokinetic with pronounced pressure/volume overload. The degree of pulmonary artery systolic hypertension and tricuspid regurgitation had signicantly worsened. A pericardial effusion is now present. Global left ventricular systolic function is slighly lower due to interventricular interaction. ___ (___): No evidence of deep venous thrombosis in either leg. Abdominal US (___): No ascites. KUB (___): Nonspecific bowel gas pattern with no evidence of obstruction or ileus. CTA chest (___): Massive pulmonary embolism with embolism burden greater on the right than the left with evidence of right heart strain. New small pericardial effusion. Brief Hospital Course: ___ yo M with PMH of bilateral pulmonary embolism here from OSH with large bilateral pulmonary emboli. ACTIVE ISSUES # Pulmonary embolism: Patient previously had an unprovoked PE in ___ for which he underwent an extensive workup for genetic causes of thromboembolic disease, all of which returned negative. However, patient does endorse an extensive family history of clotting so a genetic etiology is definitely possible. Current PE also unprovoked. No recent history of surgery, hospitalization, air travel, or prolonged immobilization. Patient was started on heparin gtt in the ED which was continued in the MICU. TTE with evidence of RV failure and ___ without any evidence of DVT. Given clinical stability, he was called out to the floor on HD#2. He was started on Coumadin with a heparin bridge. Patient therapeutic on Coumadin ___ for which heparin gtt was discontinued. Stable INR on discharge. Per discussion with his outpatient hematologist, patient should continue Coumadin with goal INR of ___ for next 6 months. After this, can consider anticoagulation with rivaroxaban. He will need lifelong anticoagulation. # Right ventricular failure: TTE from ___ with RV hypokinesis, severe TR, and pulmonary hypertension. Findings were consistent with chronic thromboembolic pulmonary hypertension. Consider referral to Cardiology if signs of CHF. # Abdominal pain: Very benign history and exam. KUB and abdominal US both unremarkable. Likely bloating and constipation. Patient was given simethicone and bowel regimen with complete resolution of symptoms. CHRONIC ISSUES # Hypertension: Held home metoprolol in the setting of PE. Restarted on discharge. # Depression: Currently stable. Continued home citalopram, trazodone, and Seroquel. # Chronic back pain: Continued home oxycodone, Tylenol, gabapentin, and tizanidine. TRANSITIONAL ISSUES - Started on Coumadin 4 mg daily - Started on bowel regimen - Goal INR ___ per outpatient hematologist - Monitor INR closely - Consider referral to Cardiology, as above - Consider ETT and PFT's as outpatient given shortness of breath, though likely secondary to PE - Consider reducing number of ___ medications - ___ with PCP scheduled - ___ with Hematology scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Gabapentin 800 mg PO TID 3. Tizanidine 4 mg PO TID 4. Multivitamins 1 TAB PO DAILY 5. ___ 1 TAB PO Q6H:PRN severe pain 6. Citalopram 40 mg PO DAILY 7. TraZODone 100 mg PO HS 8. Aspirin 81 mg PO DAILY 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 10. QUEtiapine Fumarate 100 mg PO QHS 11. Omeprazole 20 mg PO DAILY 12. BuPROPion (Sustained Release) 150 mg PO QAM Discharge Medications: 1. BuPROPion (Sustained Release) 150 mg PO QAM 2. Citalopram 40 mg PO DAILY 3. Gabapentin 800 mg PO TID 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY 6. QUEtiapine Fumarate 100 mg PO QHS 7. Tizanidine 4 mg PO TID 8. TraZODone 100 mg PO HS 9. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Capsule Refills:0 10. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth DAILY Disp #30 Capsule Refills:0 11. Simethicone ___ mg PO QID gas RX simethicone 80 mg 1 tablet by mouth four times a day Disp #120 Tablet Refills:0 12. Warfarin 4 mg PO DAILY16 RX warfarin [Coumadin] 2 mg 2 tablet(s) by mouth DAILY AS DIRECTED Disp #60 Tablet Refills:0 13. Metoprolol Succinate XL 25 mg PO DAILY 14. ___ 1 TAB PO Q6H:PRN severe pain Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Massive bilateral pulmonary embolism - Right heart failure Secondary diagnoses: - Hypertension - Depression - Chronic low back pain - Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking care of you while you were a patient at ___. You came to us with chest pain and shortness of breath due to another pulmonary embolism. You were treated with heparin and then Coumadin which resulted in improvement in your symptoms. You will need to take Coumadin for the rest of your life to prevent this from happening again. It is VERY important that you take your Coumadin every day as directed by Dr. ___. Please go to Dr. ___ tomorrow to have your labs checked. We wish you all the best. Followup Instructions: ___
19827091-DS-19	19,827,091	27,067,256	DS	19	2202-07-08 00:00:00	2202-07-08 13:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L hip and L elbow pain Major Surgical or Invasive Procedure: ___: Left hip Open reduction, internal fixation with three 7.3 mm screws. History of Present Illness: ___ mech fall while ice skating, L hip pain. No pain elsewhere. No headstrike or LOC. Transferred from OSH for L femoral neck fx. Injury at 11am. Last PO at 8am. Past Medical History: Osteopenia Family History: Non contributory Physical Exam: PE: 98.0 67 110/67 16 98% NAD A&Ox3 LLE: WWP, +DP and ___ short and ER +TA, ___, G/S SILT s/s/spn/dpn/pn's Pertinent Results: ___ 04:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 04:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 04:20PM GLUCOSE-111* UREA N-17 CREAT-0.7 SODIUM-140 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-27 ANION GAP-12 ___ 04:20PM estGFR-Using this ___ 04:20PM WBC-10.7# RBC-4.12* HGB-13.1 HCT-37.2 MCV-90 MCH-31.7 MCHC-35.1* RDW-12.6 ___ 04:20PM NEUTS-91.3* LYMPHS-5.3* MONOS-2.9 EOS-0.1 BASOS-0.3 ___ 04:20PM PLT COUNT-164 ___ 04:20PM ___ PTT-34.8 ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have L hip fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for an ORIF L hip, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to <<>> was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch down weight bearing in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. While inpatient, the patient c/o left elbow pain related to her initial fall. L elbow plain films were obtained and a nondisplaced Left radial head fracture was revealed. She may be weight bearing as tolerated in the left upper extremity. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Of note, an incidental finding was found on pre operative chest xray. The finding of a nodular focus projecting over the right upper lung was relayed to the patient and she has been advised to seek further evaluation and management with her PCP. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Doses RX enoxaparin 40 mg/0.4 mL 40 mg syringe daily Disp #14 Syringe Refills:0 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #50 Tablet Refills:0 5. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: L hip fracture L radial head fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - You can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - Touch Down Weight Bearing LLE - Weight Bearing as tolerated LUE Physical Therapy: Weight Bearing as tolerated Left upper extremity Touch Down Weight Bearing Left lower extremity Treatments Frequency: You may remove post operative dressing on post operative day #5. Followup Instructions: ___
19827113-DS-19	19,827,113	26,218,115	DS	19	2131-01-01 00:00:00	2131-01-03 10:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ampicillin Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Left Chest tube placement ___ History of Present Illness: ___ who underwent an uneventful left subclavian portacath placement yesterday as an outpatient procedure presented today for chemotherapy with complaints of pleuritic chest pain. Her postop CXR showed no pneumothorax. A CXR obtained today showed a large left pneumothorax. Past Medical History: PMH: right breast CA PSH: port placement Meds: ativan prn, vicodin prn Allergies: ampicillin Social History: ___ Family History: - Sister melanoma in ___ - M-aunt ovarian ca age ___ - M-g-fa throat ca - Father basal cell - P-g-ma breast ca in ___ - P-g-fa GU cancer (bladder v. prostate?) - P-g-g-fa prostate ca Physical Exam: Afebrile, vital signs stable. Left port site clean with no erythema or drainage RRR, lungs clear bilaterally Abd soft, nontender Brief Hospital Course: Mrs. ___ was admitted on ___ with a delayed left pneumothorax after left subclavian port placement on ___. A ___ chest tube was placed successfully into the left chest to decompress the pneumothorax in the ED. A post-placement CXR showed re-expansion of the lung with resolution of the pneumothorax. The CT remained to suction overnight and was placed to waterseal on HD2. A post-waterseal CXR showed no PTX. The CT was then removed and post-pull CXR showed no PTX. She was discharged home with appropriate follow-up. Medications on Admission: ativan prn, vicodin prn Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 2. Lorazepam 0.5 mg PO Q8H:PRN anxiety RX lorazepam 0.5 mg 1 by mouth q8hrs prn Disp #30 Tablet Refills:0 3. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q4H:PRN pain RX hydrocodone-acetaminophen 5 mg-500 mg 1 tablet(s) by mouth q4hrs prn Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pneumothorax Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted after you developed a pneumothorax and had a chest tube placed. You did well after this and the following day the chest tube was pulled. Please call or return to the emergency room if you have any concerning signs or symptoms or any of the symptoms mentioned below. Also, please follow up in clinic. Followup Instructions: ___
19827186-DS-18	19,827,186	21,495,720	DS	18	2146-02-14 00:00:00	2146-02-14 12:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: OTOLARYNGOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: aspiration pneumonia, diarrhea Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ with HTN, HLD, DM, DVT on Eliquis, and T2 N1 M0 p16+ squamous cell carcinoma of the left base of tongue and tonsil s/p resection of left tonsil/BOT, bilateral neck dissection, submental flap, and tracheostomy ___ who was re-admitted from home in the setting of dyspnea with purulent secretions from stoma site and concern for aspiration pneumonia. He was admitted to SICU for treatment of hypotension requiring pressors and airway watch. Past Medical History: Type 2 diabetes Hypertension Hyperlipidemia Chronic phlebitis of both lower legs Prior lumbar spine fracture GI bleeding ?dementia Sick sinus syndrome, status post permanent pacemaker. CKD. Creatinine 1.4 ___ Erectile dysfunction Prostate Cancer. Follows with Dr. ___ in urology. Pursuing a watch and wait strategy "3 massive bleeds, one episode GI bleeding, one episode hemoptysis, and on the last admission was bleeding from the right kidney and bladder" Social History: ___ Family History: Non-contributory Physical Exam: General: No apparent distress HEENT: Incision C/D/I; stoma site remains open with improved erythema and secretions Cardiac: Regular rate Respiratory: Unlabored breathing without stridor or stertor, strong voice Abd: G tube in place, NTND Neuro: Alert and oriented, communicative Pertinent Results: ___ 07:05PM BLOOD WBC-9.0 RBC-3.95* Hgb-11.8* Hct-36.9* MCV-93 MCH-29.9 MCHC-32.0 RDW-15.8* RDWSD-54.0* Plt ___ ___ 04:30AM BLOOD WBC-11.7* RBC-3.86* Hgb-11.3* Hct-36.4* MCV-94 MCH-29.3 MCHC-31.0* RDW-15.9* RDWSD-54.9* Plt ___ ___ 02:20PM BLOOD Neuts-77* Bands-11* Lymphs-5* Monos-6 Eos-0* ___ Metas-1* AbsNeut-15.05* AbsLymp-0.86* AbsMono-1.03* AbsEos-0.00* AbsBaso-0.00* ___ 07:05PM BLOOD Plt ___ ___ 07:05PM BLOOD ___ PTT-31.1 ___ ___ 09:29AM BLOOD Glucose-191* UreaN-17 Creat-1.0 Na-140 K-4.4 Cl-101 HCO3-27 AnGap-12 ___ 07:05PM BLOOD Glucose-166* UreaN-15 Creat-1.0 Na-143 K-3.7 Cl-103 HCO3-28 AnGap-12 ___ 02:20PM BLOOD ALT-14 AST-25 AlkPhos-74 TotBili-0.9 ___ 09:29AM BLOOD Albumin-3.0* Calcium-9.0 Phos-2.7 Mg-1.8 ___ 07:05PM BLOOD Vanco-17.9 Brief Hospital Course: The patient was transferred to the Otolaryngology-Head and Neck Surgery Service after original admission to the SICU. His full hospital course was ___ His SICU stay was ___. Hospital Course by Systems: Neuro: Pain was well controlled, initially with IV regimen which was transitioned to oral regimen once tolerating oral intake. Post-operative anti-emetics were given PRN. Cardiovascular: Initially upon admission the patient required pressor support due to hypotension in the setting of septic shock. Gradually his blood pressures improved and he was able to be weaned off of pressors which the patient tolerated well. Patient has a pacemaker which was interrogated and reprogrammed on HD1 which improved heart rate and pressures. EKG on admission unremarkable. Pulmonary: Upon admission the patient was noted to have copious secretions and concern for multifocal pneumonia on CT chest obtained in the ED. He required frequent suctioning, chest ___, and was started on broad spectrum antibiotics for pneumonia. Oxygen was weaned and the patient was ambulating independently without supplemental oxygen prior to discharge. HEENT: Patient was started on frequent suctioning and had stoma care on patient decannulation site. This was done with wet to dry gauze. GI: Diet was advanced as tolerated via G tube. He initially was started on trickle tube feeds at 10cc. Reglan was avoided while in patient due to potential reflux. On HD3 he started to have continuous loose stool. His tube feeds were continued and a flexiseal was inserted and stool output was closely monitored. Nutrition and GI were consulted and it was recommended to hold tube feeds for 12 hours and place on standing Imodium, followed by a change in tube feeds with improvement in stool output. By ___ his flexiseal was removed due to minimal loose stools. He continued on goal tube feeds and Imodium. SLP evaluated the patient while inpatient and noted the patient to have gross aspiration. GU: Patient was able to void independently. Heme: Received heparin subcutaneously and pneumatic compression boots for DVT prophylaxis. Patient has a history of DVT and his home Eliquis was held for his first hospital day. Given no operative intervention the patient's Eliquis was resumed on hospital day 2. Endocrine: Monitored without any remarkable issues. Was on RISS while inpatient ID: Given his vitals and symptoms he underwent an infectious workup in the ED. Sputum Cx cancelled due to contamination, UCx pending, OSH BCx w/ Haemophilus, OSH Sputum Cx w/ Strep pneumo, H.influenzae, Serratia marcescens. He was started on Vancomycin and Cefepime ___. He was also started on Flagyl ___. He was weaned to levofloxacin on ___. He remained stable and the levofloxacin was stopped on ___. At time of discharge, the patient was in stable condition, ambulating and voiding independently, and with adequate pain control. The patient was given instructions to follow-up in clinic with Dr. ___ as scheduled. Patient was given detailed discharge instructions outlining wound care, activity, diet, follow-up and the appropriate medication scripts. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Finasteride 5 mg PO DAILY 4. Pravastatin 40 mg PO QPM 5. Pregabalin 100 mg PO BID 6. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 3. LOPERamide 2 mg PO Q6H diarrhea 4. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain 5. Allopurinol ___ mg PO DAILY 6. Apixaban 2.5 mg PO BID 7. Finasteride 5 mg PO DAILY 8. Pravastatin 40 mg PO QPM 9. Tamsulosin 0.4 mg PO QHS 10. HELD- Pregabalin 100 mg PO BID This medication was held. Do not restart Pregabalin until you not longer require oxycodone Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: bilateral multifocal pneumonia, diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Otolaryngology Head and Neck Surgery Discharge Instructions ACTIVITY Go home and rest today. Walking is encouraged. FLUIDS & DIET YOU SHOULD NOT TAKE ANY FOOD BY MOUTH Formulas should be given at room temperature. Cover and place unused formula in the refrigerator. GIVING MEDICATION In general, it is best if all medications are in a liquid form for G-tube administration. Liquid medications are less likely to clog the G-tube. Mix the liquid medication with 30 mL (or amount recommended by your health care provider) of warm water. Draw up the medication into the syringe. Attach the syringe to the G-tube and slowly push the mixture into the G-tube. After giving the medication, draw up 30 mL of warm water in the syringe and slowly flush the G-tube. For pills or capsules, check with your health care provider first before crushing medications. Some pills are not effective if they are crushed. Some capsules are sustained-release medications. If appropriate, crush the pill or capsule and mix with 30 mL of warm water. Using the syringe, slowly push the medication through the tube, then flush the tube with another 30 mL of tap water. MEDICATIONS Take pain medication as prescribed. Resume other medications as prescribed except any aspirin or aspirin containing products unless cleared by your surgeon. CARE OF PROCEDURE SITE Apply vasoline ointment to any skin incision twice a day. You may shower You can replace the occlusive dressing site over your neck stoma as needed. Use 1 layer of 2 inch silk tape, then a folded piece of 4x4 gauze, then 1 layer of 2 inch silk tape. WHEN TO CALL YOUR DOCTOR Excessive redness of your incision site Fever greater than 101 degrees Fahrenheit Sudden excessive swelling of incision site For questions or problems, please call ___ and ask to speak to the nurse during clinic hours. After hours, or on weekends, dial ___ and ask the operator to page the Otolaryngology resident on-call. Followup Instructions: ___
19827413-DS-11	19,827,413	29,957,587	DS	11	2171-12-11 00:00:00	2171-12-11 20:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: levofloxacin / Anesthetics - Amide Type Attending: ___. Chief Complaint: Dyspnea On Exertion, Abnormal Labs Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o seronegative RA admitted with SOB in the setting of pericardial and pleural effusions. Patient was seen by her PCP at ___ on ___ for left sided pleuritic chest pain and dry cough which began on ___. She notes that she never had fever or productive cough, no sick contacts. CXR at that visit showed minimal R basilar infiltrate vs atelectasis, WBC 16.6. Pt was prescribed a Z pack for presumed CAP and returned to ___ ___ ___ for continued dyspnea and left sided rib pain. Repeat CXR showed possible L pleural effusion and associated atelectasis vs PNA. Pt was prescribed doxycycline 100mg BID x 10 days and a CTA chest was obtained which was negative for PE but showed small left pleural effusion with associated atelectasis and/or infiltrate and moderate pericardial effusion. Repeat WBC rose to 17.2 and doxycycline was changed to Augmentin on ___. Pt reported continued cough, SOB and pleuritic pain and was advised to report to ED for further work up. She initially declined to go to ED, but agreed after phone discussion with PCP ___ ___ for worsening SOB. Pt reports that she has had intermittent chest discomfort when laying flat for the last several weeks. Of note, pt had been on MTX for several months, but this was put on hold in the last few weeks due to concern for PNA. Additionally, pravastatin was recently discontinued due to LFT abnormalities. In the ED initial vitals were:99.7 90 133/46 25 97% - Pulsus <10 - Labs were significant for WBC 13.1, normal lactate, ALT 50, AST 46, AP 477. - CXR showed left pleural effusion - Patient was given IV levofloxacin and admitted to medicine for further management. Vitals prior to transfer were: 99.7 90 133/46 25 97% On the floor, pt reports that she is hungry but otherwise has no complaints. Past Medical History: Seronegative RA HLD Osteoporosis Erythema nodosum DJD of hip Social History: ___ Family History: Pt does not know detailed family history, noting that she has no living relatives at this point, but does recall that "all the women had arthritis." Physical Exam: Admission exam: Vitals - T: 99.5 154/61 101 RR 18 96% RA 76.9kg GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles, diminished breath sounds L base ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose, second toes of both feet deviated medially PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge exam: Vitals:98.5 150/75 82 18 100% RA pulsus 5 General: well-appearing elderly woman, no acute distress HEENT: AT/NC, EOMI, PERRL, anicteric sclera NECK: nontender supple neck CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission labs: ___ 12:05AM BLOOD WBC-13.1* RBC-2.96* Hgb-9.1* Hct-26.6* MCV-90 MCH-30.9 MCHC-34.4 RDW-14.2 Plt ___ ___ 12:05AM BLOOD Neuts-81.5* Lymphs-12.9* Monos-4.1 Eos-1.3 Baso-0.2 ___ 12:05AM BLOOD ___ PTT-36.1 ___ ___ 12:05AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-135 K-4.6 Cl-96 HCO3-24 AnGap-20 ___ 12:05AM BLOOD ALT-50* AST-46* AlkPhos-477* TotBili-0.4 ___ 12:05AM BLOOD Albumin-3.7 Iron-24* ___ 12:05AM BLOOD proBNP-456* ___ 12:05AM BLOOD cTropnT-<0.01 Pertinent labs: ___ 10:40AM BLOOD RheuFac-16* CRP-247.9* ___ 05:35PM BLOOD C3-263* C4-51* ___ 07:35AM BLOOD GGT-335* ___ 12:05AM BLOOD calTIBC-241* Ferritn-1178* TRF-185* ___ 12:05AM BLOOD Albumin-3.7 Iron-24* Discharge labs: ___ 07:00AM BLOOD WBC-11.6* RBC-3.17* Hgb-9.8* Hct-28.5* MCV-90 MCH-30.8 MCHC-34.2 RDW-14.1 Plt ___ ___ 07:00AM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-139 K-5.1 Cl-101 HCO3-27 AnGap-16 ___ 07:00AM BLOOD ALT-36 AST-30 AlkPhos-367* TotBili-0.3 ___ 07:00AM BLOOD Calcium-10.0 Phos-4.3 Mg-2.5 Imaging: ___ CXR: IMPRESSION: No evidence for current pneumonia. Hyperexpanded, but clear lungs. No pleural effusions. ___ RUQ u/s: IMPRESSION: Mild central intrahepatic biliary dilatation, status post cholecystectomy, which is nonspecific given lack of prior imaging. ___ Echo: Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion without echocardiographic evidence for hemodynamic compromise. IMPRESSION: Suboptimal image quality. Small circumferential pericardial effusion without evidence for hemodynamic compromise. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Increased PCWP. ___ foot xray: IMPRESSION: No acute bony injury. Medial subluxation of the second toe in relation to the second metatarsal heads bilaterally. Mild degenerative changes of bilateral first MTP joints, left side worse than right. ___ MRCP: IMPRESSION: Minimal intra and extrahepatic bile duct dilation is within the acceptable range post cholecystectomy. No obstructing stone or mass lesion is identified. Known complex pericardial effusion. Brief Hospital Course: Impression: Ms. ___ is a ___ lady with h/o seronegative RA presenting with DOE and cough in the setting of recently diagnosed pleural and pericardial effusions, most likely due to viral process. # Pericardial effusion: Outpatient CTA showed moderate-sized pericardial effusion and patient presented with pleuritic, positional chest discomfort suggestive of pericarditis. There were no EKG changes c/w pericarditis and patient remained stable with normal BP and pulsus. Echo showed a small pericardial effusion without any tamponade physiology. Given the presence of both a pericardial effusion and pleural effusion, rheumatology was consulted for possibility of serositis complicating an underlying rhematologic disorder. They did not believe her symptoms were consistent with either RA or lupus. Diagnostic tests were sent and pending at discharge, including ___, anti-Sm Ab, anti-dsDNA Ab, RNP Ab, anti-CCP Ab, Ro & La. Patient treated with aspirin 650mg TID and colchicine 0.6 BID and will continue these for 2 weeks and 3 months respectively. # Dyspnea: Outpatient CTA noted a small left-sided pleural effusion and patient had persistent dyspnea for 3 weeks. She completed a course of azithromycin and trial doxycycline and augmentin and was started on levofloxacin in the ED. Antibiotics were held and repeat CXR as well as bedside ultrasound did not show any effusion. Dyspnea most likely multifactorial from body habitus, pericardial effusion, and atelectasis. # LFT abnormalities: Patient presented with mild transaminitis with markedly elevated alkaline phosphatase and GGT on admission. RUQ ultrasound showed mild central intrahepatic biliary dilatation and thus, MRCP was performed. This study showed minimal intra and extrahepatic bile duct dilation without any obstructing stones or mass lesions. ALT/AST/ALP trending down at discharge. # Leukocytosis: Patient with increasing leukocytosis as outpatient to peak of 17.2 and on admission was 13.1. Most likely due to a viral process such as ___ virus, leading to systemic inflammation and pericarditis. CRP also elevated to 250 and ferritin as high as 1100. Leukocytosis downtrending on discharge to 11. # Chronic Normocytic Anemia: HGB on admission noted to be 9.4 on ___ from prior baseline 10.7 as of ___ per ___ records. Iron studies consistent with iron deficiency but patient refused iron supplementation. # Rheumatoid arthritis: Patient with history of seronegative RA followed by ___ Rheumatologist ___. She was previously on methotrexate which is being in the setting of PNA. Rheumatologic evaluation recommended x-rays of the foot to evaluate for bony erosions, but only showed mild degenerative changes. Per our rheumatology colleagues, we would recommend re-evaluation of the diagnosis of RA. Transitional issues: - pending labs: RO & LA, RNP Ab, anti-CCP Ab, ___, dsDNA, anti-SM antibody - MRCP final read pending at discharge - patient discharged with ASA tid x2 weeks and colchicine BID x 3mo - persistent thrombocytosis at discharge, patient will have labs drawn on ___ after discharge - patient refused iron supplementation despite iron deficiency - please re-consider diagnosis of RA per rheumatology Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Desipramine 250 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Methocarbamol 750 mg PO BID:PRN pain 5. Aspirin 325 mg PO DAILY 6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Discharge Medications: 1. Aspirin 650 mg PO TID RX aspirin 650 mg 1 tablet(s) by mouth three times a day Disp #36 Tablet Refills:0 2. Desipramine 250 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Methocarbamol 750 mg PO BID:PRN pain 5. Omeprazole 20 mg PO DAILY 6. Outpatient Lab Work Please check CBC, chem-7, and LFTs including: Na, K, Cl, HCO3, BUN, Cr, Glc, AST, ALT, ALP, tbili Fax results to: ___. fax #: ___ 7. Colchicine 0.6 mg PO BID Duration: 48 Hours RX colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: viral pericarditis Secondary diagnosis: rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your stay at ___. You were admitted for an expedited workup of multiple issues, including your shortness of breath, elevated ALP, and for fluid around your heart. You underwent several diagnostic tests, including a liver ultrasound, an MRI of your liver, an echocardiogram, and x-rays of your foot. These showed that you do not have any life-threatening conditions that we can identify. You were also evaluated by our rheumatology team, who did not believe your symptoms were related to your underlying rheumatoid arthritis. We sent a number of studies that are pending at discharge. Please follow-up with your PCP within the next week to continue monitoring your symptoms. Please continue to take your aspirin three times a day for 2 weeks and colchicine twice a day for 3 months to help with the chest pain. Please have your labs drawn on ___ next week so your PCP can closely monitor your progress. We recommended iron supplementation to help with your anemia but understand you do not wish to take it. Please re-consider this decision as treating your anemia may make you feel better and less tired. It was a pleasure taking care of you. Best wishes, Your ___ Team Followup Instructions: ___
19827590-DS-13	19,827,590	20,065,353	DS	13	2147-07-31 00:00:00	2147-07-31 15:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___ Chief Complaint: Hypoxia and Delirium Major Surgical or Invasive Procedure: None History of Present Illness: ___ MEDICINE ATTENDING ADMISSION NOTE . . Date: ___ Time: ___ _ ________________________________________________________________ PCP: Name: ___ Location: ___ Address: ___ FLOOR, ___ Phone: ___ Fax: ___ . Cardiologist at ___ CC: ___ and crackles _ ________________________________________________________________ History obtained from dtr ___ . HPI: ___ w/ hx of HTN, HLD, h/o heavy tobacco use and diet controlled DM presenting with SOB. She had been admitted for pneumonia. She was just discharged from ___ 4 days ago to ___ for rehab. Her daughter saw her yesterday and her speech was altered as though her tongue was full. She was evaluated by the NP and was not thought to have had a stroke. She still had a productive cough of clear phlegm. Was noted to be more SOB yesterday. Required 2L NC. Today found to be hypoxic 85% on 15L NRB. Upon d/c from ___ on ___ she was 95% on RA. She was bradycardic and unresponsive at first. Became more awake with EMS although still confused. On Coumadin for a-fib although was held recently due to supratherapeutic INR. Upon arrival to the ED she was hypoxic, brady, 84% NRB 15L, inc mental status with NRB, +confusion. triggered for hypoxia 87%RA, hx of She was started on bipap, given vanc/cefepime/Lasix and ASA 325 . Admitted to ___ on ___. Cr on admission 1.6 -> 2.5 and was 2.4 on discharge. Increased with IV diuresis. She was rhinvirous positive but with elevated pro-calcitonin treated with unasyn-> doxycycline. She was also on bipap briefly and also received IV Lasix held baseline Cr = 1.6 In ER: (Triage Vitals: 42 \| 87% Non-Rebreather -> \|0 \| 97.5`\|87 \| 117/65 \|22 \|RA ) . PAIN SCALE: ___ She denies chest pain. She reports that her breathing is OK. It is difficult to obtain a review of system because she asks me to ask her dtr. ___ her daughter reports that she lost 6 lbs during her recent admission. Limited ROS is otherwise negative except as above. Past Medical History: Atrial fibrillation - diagnosed in ___ DM HTN Social History: ___ Family History: Her sister died of complications from DM at age ___. Physical Exam: ADMISSION EXAM: Vitals: 97.7 PO 130 / 70 71 22 97 2L NC CONS: NAD, comfortable appearing with occasional periods of tachypnea c/w Cheynes Stokes breathing HEENT: ncat anicteric MMM CV: s1s2 rr no m/r/g RESP: CTAB with decreased BS at the bases. No rhonchi or wheezes GI: +bs, soft, NT, ND, no guarding or rebound MSK:no c/c/e 2+pulses SKIN: no rash NEURO: face symmetric speech fluent, ___, ___ ___ strength in b/l upper and lower extremities PSYCH: calm, cooperative, sometimes reluctant to answer questions. LAD: No cervical LAD DISCHARGE EXAM: Vitals: 98.1 108/62 68 18 98% RA Gen: sitting up and eating breakfast Weight: 106.31 24 hr I/O: 260/475, net -215cc HEENT: Anicteric, MMM, JVP not elevated Cardiovascular: irregular, ___ systolic murmur best heard at apex Pulmonary: Mild left basilar crackles, otherwise clear GI: Soft, non-tender, non-distended, bowel sounds present, no HSM Extremities: No edema Pertinent Results: LABS: ================================= ADMISSION LABS: Cr = 2.4 on ___ EGFR = 17 Hgb = 8.1 INR = 4.3 ___ 02:51PM TYPE-ART PO2-431* PCO2-40 PH-7.38 TOTAL CO2-25 BASE XS-0 ___ 02:51PM O2 SAT-99 ___ 12:14PM ___ PO2-29* PCO2-48* PH-7.31* TOTAL CO2-25 BASE XS--3 ___ 12:14PM LACTATE-2.6* K+-4.6 ___ 11:58AM GLUCOSE-236* UREA N-68* CREAT-2.2* SODIUM-146* POTASSIUM-6.9* CHLORIDE-109* TOTAL CO2-18* ANION GAP-26* ___ 11:58AM estGFR-Using this ___ 11:58AM cTropnT-0.16* ___ ___ 11:58AM WBC-7.9 RBC-2.98* HGB-9.3* HCT-31.0* MCV-104* MCH-31.2 MCHC-30.0* RDW-17.9* RDWSD-64.7* ___ 11:58AM NEUTS-80.6* LYMPHS-13.7* MONOS-4.8* EOS-0.0* BASOS-0.1 NUC RBCS-1.6* IM ___ AbsNeut-6.39* AbsLymp-1.09* AbsMono-0.38 AbsEos-0.00* AbsBaso-0.01 ___ 11:58AM PLT COUNT-194 Hgb was 8.4 on d/c ___ DISCHARGE LABS: ___ 05:45AM BLOOD WBC-11.7* RBC-2.81* Hgb-8.7* Hct-28.5* MCV-101* MCH-31.0 MCHC-30.5* RDW-17.5* RDWSD-62.2* Plt ___ ___ 05:45AM BLOOD Glucose-87 UreaN-39* Creat-1.8* Na-143 K-4.5 Cl-108 HCO3-28 AnGap-12 ___ 06:20AM BLOOD ___ ___ 05:45AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 MICRIO ================================= ___ URINE CULTURE: negative ___ MRSA screen: negative ___ blood culture x 2: no growth to date IMAGING ================================= CXR: IMPRESSION: Pulmonary edema, pleural effusions, possible lower lung pneumonia. Echo= EF 40-45% down from 58% in ___ with moderate to severe MR. ___: Conclusions The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The effective regurgitant orifice is >=0.40cm2. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated in some views (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Biatrial enlargement. Moderate LVH. Moderate LV dysfunction (LVEF 35-40%). Severe mitral regurgitation. Moderate TR with mild pulmonary artery systolic HTN. Brief Hospital Course: Ms. ___ is an ___ woman with h/o AF (on coumadin), HFrEF (EF: 35%), severe MR, moderate TR, HTN, HLD, heavy tobacco use who presents with shortness of breath and hypoxia concerning for acute on chronic systolic heart failure exacerbation. #ACUTE RESPIRATORY FAILURE/HYPOXIA REQUIRING BIPAP Ms. ___ was admitted for hypoxemia likely in the setting of a heart failure exacerbation which elevated NT-BNP, hypoxia and CXR showing pulmonary edema. She required BiPAP in the ED, but improved with diuresis. She had troponin peak at 0.22 likely in the setting of exacerbation, but EKG without acute ischemia. Causes for HF exacerbation were not immediately clear though possible ___ to PNA or AF with RVR. Given her severe MR, she is likely an increased risk for acute pulmonary edema. She received another dose of IV Lasix on the floor. Her respiratory status improved significantly and she was weaned to room air. She had ___ which showed moderately depressed EF of 35-40% and severe MR. ___ was placed on Lasix 10mg PO with maintenance of euvolemia. She is also on Metoprolol and Atorvastatin. She is not currently on an ACEi given her fluctuating renal function. This should be addressed as an outpatient. On discharge, her weight was 106.31 pounds and NT-BNP was 10,443 down from 34,176 on admission. She should follow up with cardiology at ___ #Pneumonia Patient had finished course of CAP after admission to ___. On admission, there was consideration of PNA given hypoxemia and LLL infiltrate. She was started on Vanc/Cefepime. Given quick clinical improvement, she was narrowed to Levaquin. She will complete 7 day course (___). #NSTEMI Troponin 0.16 -> 0.22 --> 0.20. Most likely demand in the setting of acute heart failure. The case was discussed with cardiology. ___ did not any WMA abnormalities. She was restarted on a low dose aspirin and continued on her beta-blocker and statin. #AFIB ON COUMADIN CHADS2 SCORE = 4 Her Coumadin was initially held. When her INR decreased to 2.8, it was restarted. However, her INR subsequently rose to 3.5, thus it was held. Her INR on discharge was 3.1. Her Coumadin dosing per ___ records is 2.5mg ___ - ___, 3.25mg on ___. She converted to SR and had HR in ___, thus metoprolol was held. Her HR improved to ___, thus she was restarted on metoprolol at 25mg Q6h and transitioned to 100mg XL daily. Coumadin was restarted at lower dose of 1.5mg at discharge. Please check INR on ___ and titrate Coumadin as needed. #ACUTE ON CHRONIC RENAL FAILURE Cr = 1.6 at baseline per ___ records. Her Cr peaked at 2.1. There seemed to be cardiorenal component as it improved with diuresis. On discharge, her Cr was 1.8. #Hypernatremia She was hypernatremic to 152 likely iso diuresis. This improved with D5W. Discharge Na was 143 and she was encouraged to have more fluids and her intake was poor. #Leukocytosis WBC noted to be increased to 11.3 on discharge, perhaps due to hemoconcentration. Patient remained afebrile and without localizing source of infection. She should complete her levofloxacin course for pneumonia as above. Please check CBC on ___ to ensure resolution. The patient is safe to discharge today, and >30min were spent on discharge day management services. TRANSITIONAL ISSUES: - Discharge wt: 106.31, creatinine: 1.8 - please call ___ cardiology at ___ or ___ to make follow-up appointment in ___ weeks - titrate coumadin as indicated: please give on ___ at reduced dose of 1.5mg and recheck on ___ - to complete levofloxacin on ___ - please check CBC and BMP on ___ to ensure stability of creatinine, sodium, and WBC - encourage PO intake - please obtain daily standing weights and if weight increases or decreases by > 3 pounds, please contact MD for titration of lasix - consider initiation of ACE-inhibitor if creatinine stabilizes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Loratadine 10 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Doxycycline Hyclate 100 mg PO Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Furosemide 10 mg PO DAILY 3. Levofloxacin 500 mg PO Q48H Duration: 1 Day last day: ___. Warfarin 1.5 mg PO DAILY16 5. Atorvastatin 20 mg PO QPM 6. Loratadine 10 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute on Chronic Systolic Heart Failure Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, it was a pleasure taking care of you during your admission to ___. You were admitted because your were having trouble breathing. This was related to back up of fluid into your lungs and pneumonia. You were treated for these conditions and you improved. It will be import for you to follow up with your cardiologist and primary care providers. Followup Instructions: ___
19827931-DS-10	19,827,931	27,817,804	DS	10	2113-01-06 00:00:00	2113-01-06 18:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: minocycline Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ lapstoroscopic appendectomy History of Present Illness: ___ male here with periumbilical pain starting around midnight, gradual onset increasing in intensity over the course of the day today. Still located around the umbilicus. Nausea without vomiting. Reported he felt he tried to urinate this morning to decrease the pain but was unable to do so. A few years ago he had an admission to a hospital for similar abdominal pain with unclear cause Past Medical History: SBO treated non-operatively last year. No etiology discovered. Acne Social History: ___ Family History: non-contributory Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 97.1 HR: 83 BP: 123/68 Resp: 20 O(2)Sat: 97 Normal Constitutional: Comfortable Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, tender periumbilical, right lower quadrant tenderness greater than left lower quadrant tenderness Skin: No rash Neuro: Speech fluent Psych: Normal mentation Pertinent Results: ___ 07:40AM BLOOD WBC-12.3* RBC-4.92 Hgb-15.0 Hct-43.1 MCV-88 MCH-30.5 MCHC-34.8 RDW-12.7 RDWSD-40.2 Plt ___ ___ 07:40AM BLOOD Neuts-73.5* Lymphs-18.8* Monos-6.1 Eos-1.1 Baso-0.3 Im ___ AbsNeut-9.00* AbsLymp-2.31 AbsMono-0.75 AbsEos-0.14 AbsBaso-0.04 ___ 07:40AM BLOOD Glucose-109* UreaN-15 Creat-1.1 Na-138 K-4.0 Cl-102 HCO3-24 AnGap-16 ___ 07:40AM BLOOD ALT-20 AST-17 AlkPhos-44 TotBili-0.7 ___ 07:40AM BLOOD Lipase-25 ___ 07:40AM BLOOD Albumin-4.8 ___: US of appendix: Dilated, noncompressible appendix, up to 14 mm in diameter, with surrounding free fluid. Findings are concerning for acute appendicitis, given the clinical history. Brief Hospital Course: Mr. ___ is a a ___ who presented ___ with a 12hr history of abd pain initially epigastric localizing to RLQ. Associated with nausea, chills, anorexia. ___ any vomiting. Has been passing flatus. Did have some urinary hesitancy this am but otherwise ___ any dysuria, hematuria. ___ any diarrhea, bloody stools, or recent weight loss. Last meal was dinner the preceding night. Abd ultrasound done at admission showed a dilated, noncompressible appendix, up to 14 mm in diameter, with surrounding free fluid, highly suggestive of acute appendicitis. After informed consent was obtained, the patient was taken to the OR for laparoscopic appendectomy. Surgery and postoperative course were uncomplicated. Following surgery the patient was admitted to the floor overnight for observation. His diet was advanced and he tolerated this well. He was able to void without issue, ambulate normally, and tolerate diet. On ___ when he met appropriate criteria he was discharged home with instructions to follow up in clinic postopertatively in ___ weeks. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain RX acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:1 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:*0 4. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with right lower quadrant pain. You underwent an ultrasound and you were reported to have a dilated appendix. These findings were consistent with appendicitis. You were taken to the operating room to have your appendix removed. You are preparing for discharge home with the following instructions: You were admitted to the hospital with acute appendicitis. You were taken to the operating room and had your appendix removed laparoscopically. You tolerated the procedure well and are now being discharged home with the following instructions: Please follow up at the appointment in clinic listed below. We also generally recommend that patients follow up with their primary care provider after having surgery. We have scheduled an appointment for you listed below. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. Don't lift more than ___ lbs for ___ weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: You may feel weak or "washed out" a couple weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You could have a poor appetite for a couple days. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: Tomorrow you may shower and remove the gauzes over your incisions. Under these dressings you have small plastic bandages called steristrips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay. Your incisions may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: Constipation is a common side effect of narcotic pain medicaitons. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Do not drink alcohol or drive while taking narcotic pain medication. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: ___
19827951-DS-17	19,827,951	22,584,001	DS	17	2159-09-24 00:00:00	2159-09-24 17:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Phenobarbital / Enalapril / Norvasc / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with mild dementia, HTN, diastolic dysfunction, and h/o syncopal episodes, now presenting s/p unwitnessed fall. . On the evening of ___ she was trying to go somewhere in her home when she attempted to reach for walker and fell. The fall was unwitnessed. She struck her forehead against the walker, but does not recall whether she lost consciousness. She is also unable recall whether she had chest pain, SOB or dizziness/lightheadedness prior to her fall. Denies visual changes. . She was unable to get up but she does not recall why. She spent the night on the floor. Her home health aide arrived in the morning and found her on the floor, whereupon she was brought to the ED. . Initial vitals in ED triage were 97.9 60 190/100 18 99% RA. Urinalysis was suggestive for UTI. She received 400mg IV ciprofloxacin, and was admitted to medicine for further management. Vitals prior to floor transfer were 95.0 66 18 131/43 95%RA. . Upon arrival to the floor, she denies any complaints. She reports feeling "pretty average". Denies headache or pain anywhere.. . <B>REVIEW OF SYSTEMS:<B> (+) Per HPI (-) Limited as she reports poor memory. Denies fever, headache, new cough or shortness of breath, chest pain/pressure/tightness, palpitations. No nausea/vomiting, diarrhea/constipation, or abdominal pain. No recent change in bladder habits. No dysuria or hematuria. Denies new rash. Denies arthralgias or myalgias. Review of systems was otherwise negative. . Past Medical History: - Dementia - HTN - Hyperlipidemia - Diastolic dysfunction (grade I per ___ ECHO) - Probable h/o rheumatic fever - Mild AS, AR, MR, mildly thickened tricuspid/mitral valves on ECHO (___) - H/o syncopal episodes which led to the implantation of a Reveal monitor in ___ removed ___ at ___ - Mild COPD - Chronic renal insufficiency (Baseline Cr~1.2-1.4) - Urinary overflow incontinence - BPPV - s/p hysterectomy - s/p cataract removal Social History: ___ Family History: Unable to corroborate. Non-contributory per OMR. Physical Exam: On admission: VS: T 95.0, BP 131/43, HR 66, RR 18, SpO2 95RA Gen: Elderly female in NAD. HEENT: 2-3cm hematoma present on L forehead. Sclera anicteric. PERRL, EOMI. MMM, OP benign, poor dentition. Neck: Supple, full ROM. No JVD. No cervical lymphadenopathy. CV: RRR. ___ holosystolic murmur at right upper sternal border. ___ systolic murmur at left upper sternal border. Chest: Diffuse wheezes bilaterally, high-pitched wheezes audible without stethoscope. Crackles at bases. Prolonged expiratory phase. Respiration unlabored, no accessory muscle use. Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or masses. Ext: WWP. No C/C/E. Distal pulses intact radial 2+, DP 2+. Skin: No rashes, ulcers, or other lesions. Neuro: CN II-XII intact. Strength ___ in upper extremities. Hip flexion ___. Knee flexion/extension 4+/5. No pronator drift. Finger-to-nose intact. Gait exam deferred. Normal speech. Cognition: Oriented to self and "hospital" but not to name of hospital or year. Does not recall examiner's name after being prompted 5 times. Forgets recent personal history. Language intact. "Okay" mood, pleasant affect. Prior to discharge: 97.8 147/53 90 18 96% RA Gen: Elderly female in NAD. HEENT: 2cm hematoma present on L forehead. Sclera anicteric. PERRL, EOMI. MMM, OP benign, poor dentition. Neck: Supple, full ROM. No JVD. No cervical lymphadenopathy. CV: RRR. ___ holosystolic murmur at right upper sternal border. ___ systolic murmur at left upper sternal border. Chest: Diffuse wheezes bilaterally. Respiration unlabored, no accessory muscle use. Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or masses. Ext: WWP. No C/C/E. Distal pulses intact radial 2+, DP 2+. Skin: No rashes, ulcers, or other lesions. Neuro: CN II-XII intact. Strength ___ in upper extremities. Hip flexion ___. Knee flexion/extension 4+/5. Pertinent Results: Admission Labs: =============== ___ 11:45AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM ___ 11:45AM URINE RBC-2 WBC-12* BACTERIA-MOD YEAST-NONE EPI-<1 ___ 11:45AM URINE HYALINE-3* ___ 10:40AM GLUCOSE-125* UREA N-28* CREAT-1.3* SODIUM-136 POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 ___ 10:40AM WBC-8.7 RBC-5.01# HGB-15.2# HCT-42.2# MCV-84 MCH-30.3 MCHC-35.9* RDW-13.4 ___ 10:40AM NEUTS-75.2* ___ MONOS-4.3 EOS-1.8 BASOS-0.4 ___ 10:40AM CK(CPK)-213* ___ 10:40AM cTropnT-<0.01 ___ 10:40AM CK-MB-7 Discharge Labs: ================ ___ 06:15AM BLOOD WBC-6.5 RBC-3.91* Hgb-12.1 Hct-33.5* MCV-86 MCH-31.0 MCHC-36.2* RDW-13.6 Plt ___ ___ 06:15AM BLOOD Glucose-104* UreaN-35* Creat-1.5* Na-139 K-5.3* Cl-107 HCO3-24 AnGap-13 ___ 06:15AM BLOOD CK(CPK)-103 Brief Hospital Course: Primary Reason for Hospitalization: =================================== Ms. ___ is a ___ woman with history of mild dementia, HTN, diastolic dysfunction, and h/o syncopal episodes, now presenting s/p unwitnessed fall with evidence of UTI on UA. . ACTIVE ISSUES: ============== # Mechanical Fall: Unwitnessed. She says the fall was mechanical due to losing hold of her walker, but is unsure whether she lost consciousness. She also does not recall whether she had preceding SOB, dizziness, or chest pain. Trauma imaging including CT head/C-spine/torso negative for acute injury. Notably she was admitted in ___nd UTI, with negative syncope workup at that time. Per previous home health aide she had frequent falls at home, and also had SOB/dizziness/fatigue at baseline. Also she does have history of syncope s/p Reveal monitor, ?symptomatic bradycardia in ___, after which diltiazem was discontinued. Her Reveal monitor has since then been removed because battery was dead. Differential diagnosis includes cardiogenic syncope, neurocardiogenic (including vasovagal/reflex) syncope, seizure, delirium, and mechanical fall. This appears most likely to be a multifactorial mechanical fall, possibly precipitated by delirium superimposed on baseline dementia given evidence of UTI on UA. Other contributors to mechanical falls include baseline weakness and gait instability per history from ___. EKG/TropT/CK-MB are nonsuggestive of ACS. Progression of known valvular disease is possible given murmurs on physical exam, but ECHO would be likely to result in little therapeutic benefit. Orthostatics negative. Medication list reviewed and with few medications that could contribute to falls. ___ was consulted and recommended d/c with rehab for intensive therapy to focus on strengthening and balance. . # UTI: Pansensitive E. coli. Denies urinary frequency or dysuria, however UTI may be contributing to her mental status and fall risk. -- Completed 3 day course of antibiotics with ciprofloxacin . # Wheezing: History of COPD. Patient Oxygenating well on room air. -- Nebulizers PRN -- Continued home fluticasone . # Acute on Chronic Renal Failure: Likely prerenal from diarrhea. Valsartan was held and patient given IV fluids. Creatinine improved towards baseline although not totally resolved before discharge to rehab - Held valsartan for now, resume PRN at rehab. . # Renal Mass: CT torso noted 15 mm hypdense lesion in the upper pole of left kidney, which may represent a hyperdense cyst vs a renal cell carcinoma. -- Patient scheduled for outpatient MRI on ___ at 4:45PM at ___ -- Results to be transmitted to patient's PCP at ___ Dr. ___ ___ . CHRONIC ISSUES: =============== # Chronic Diastolic Heart Failure: Stable. Currently no findings of decompensated heart failure including crackles, JVD or peripheral edema on exam. -- Held valsartan due to ___ -- Continued ASA 325mg daily. . # Dementia: Stable. Patient generally oriented X 2, although she intermittently forgot where she was. -- Continued donepezil 10mg daily. . # Hypertension: Currently appears well controlled. -- Held valsartan due to ___. Resume PRN at rehab. . # Hyperlipidemia: Stable. -- Continued atorvastatin 10mg daily. . . CONTINUITY OF CARE: ==================== -- Patient scheduled for outpatient MRI to evaluate to renal mass concerning for RCC. Scheuled on ___ at 4:45PM at ___ ___. Results to be transmitted to patient's PCP at ___ Dr. ___ Medications on Admission: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: -Fall -Urinary Tract Infection -Renal Mass -Acute Kidney Injury Secondary: -Chronic Kidney Disease -Urinary Incontinence -Hypertension -Dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___: It was a pleasure taking care of you at ___. You were admitted after an unwitnessed fall while you were at home. While in the hospital, you were found to have a urinary tract infection. You were treated with antibiotics for your urinary tract infection as well as nebulizers to help your breathing. One of your blood pressure medications was stopped temporarily (Valsartan). Your doctor ___ resume this later when your blood pressure comes back up. Please also continue to take all your other home medications as you were previously. During your CT scan, a mass was noted in your kidney. You will need an MRI to look at the mass in more detail to figure out what it is. Followup Instructions: ___
19828318-DS-11	19,828,318	22,578,961	DS	11	2150-08-19 00:00:00	2150-10-03 10:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Mr. ___ is a ___ male with a past medical history of UC who presented with abdominal cramping and pain. His symptoms first started with the development of perirectal pain the day after ___. He visited an urgent care where the MD thought he saw an abscess. MD at urgent care was going to attempt I+D but patient declined. He was started on augmentin at the time. He was referred by his PCP to colorectal surgery clinic, where no abscess was appreciated on exam. However, given marked tenderness to palpation, they scheduled him for outpatient MRI. He describes the pain as excruciating pain that feels like a blowtorch. It is located along his lower back and upper buttocks. This pain has somewhat improved but is still presented. He took the augmentin until ___. However, around five days after starting the augmentin he developed cramping right sided abdominal pain. He also had frequent loose, sometimes bloody stools. He reports ___ bowel movements a day. The pain felt like his typical UC flares but he also had a severe, spasm-like pain that was new for him. He also developed a fever to 101. For these reasons he reported to an OSH ED. He had a CT scan concerning for portal venous gas and was referred to ___ for further surgical evaluation. He takes entyvio which has been very helpful. He previously had multiple flares a year, now only one or less. This is however his most severe flare. He had prior flares that required hospitalization and IV steroids. In the ED, he was seen by both colorectal surgery and ACS, who felt that abdomen was benign. They did not feel there was any need for acute surgical intervention. Of note, he reports many (>100) episodes of nephrolithiasis. He was told that stones were both calcium and uric acid. Past Medical History: Ulcerative colitis X ___ years Gout Nephrolithiasis Cervical radiculopathy Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: Admission Physical Exam: ======================== VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended. Tender to palpation over right side with some voluntary guarding, no rigidity. No perianal abscess visualized, tender over gluteal cleft with some erythema and warmth but no fluctuance appreciated GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge Physical Exam: ======================== VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended. Tender to palpation over right side with some voluntary guarding, no rigidity. No perianal abscess visualized, tender over gluteal cleft with some erythema and warmth but no fluctuance appreciated GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: Admission Labs: =============== ___ 01:55AM BLOOD WBC-9.5 RBC-4.59* Hgb-13.2* Hct-40.8 MCV-89 MCH-28.8 MCHC-32.4 RDW-14.2 RDWSD-45.6 Plt ___ ___ 01:55AM BLOOD Neuts-65.5 ___ Monos-9.4 Eos-2.0 Baso-0.4 Im ___ AbsNeut-6.18* AbsLymp-2.12 AbsMono-0.89* AbsEos-0.19 AbsBaso-0.04 ___ 01:55AM BLOOD ___ PTT-25.5 ___ ___ 01:55AM BLOOD Glucose-97 UreaN-6 Creat-1.1 Na-140 K-4.2 Cl-101 HCO3-24 AnGap-15 ___ 01:55AM BLOOD ALT-18 AST-16 AlkPhos-91 TotBili-1.3 ___ 01:55AM BLOOD Lipase-14 ___ 01:55AM BLOOD Albumin-4.0 ___ 06:50AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9 ___ 01:55AM BLOOD CRP-44.8* ___ 06:29AM BLOOD CRP-30.2* ___ 03:05PM BLOOD CRP-10.5* Imaging: ======== MR Pelvis: 1. No evidence of perianal fistula. 2. Rectal wall thickening with intramural fat, suggest chronic inflammation. 3. Internal hemorrhoids noted. Sigmoidoscopy: Decreased vascularity, erythema and edema with ___ small erosions. in the colon (biopsy, biopsy) Limited view due to poor preparation. No retroflexion performed due to patient pain and poor tolerance. Small anal fissure at the right aspect, which correlated to an area of increased pain. Otherwise normal sigmoidoscopy to descending colon Discharge Labs: =============== Brief Hospital Course: Mr. ___ is a ___ male with a past medical history of UC who presented with abdominal cramping and pain likely secondary to IBD flare. ACUTE/ACTIVE PROBLEMS: # Ulcerative colitis: # Perianal pain: Presented with severe abdominal pain and cramping along with bloody diarrhea. OSH CT was notable for portal venous gas, but his abdomen was benign with negative lactate X 2 which is reassuring. Acute ischemia was thought to be very unlikely. He was also seen by colorectal surgery who found no need for operative intervention. He was initially treated with IV antibiotics but these were stopped after condition remained stable. He also reported rectal pain but MR ___ was negative for any abscess or fistula. C diff was negative. He was evaluated by GI and started on IV solumedrol with improvement in pain and diarrhea Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mesalamine ___ 2400 mg PO BID 2. Entyvio (vedolizumab) 300 mg injection EVERY 8 WEEKS Discharge Disposition: Home Discharge Diagnosis: Primary: Ulcerative colitis flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came in with abdominal pain. We think this was due to a flare of your ulcerative colitis. You were treated with IV steroids, and oral steroids and your pain improved. It was a pleasure taking care of you, and we're happy that you are feeling better! Followup Instructions: ___
19828318-DS-12	19,828,318	24,439,943	DS	12	2150-08-26 00:00:00	2150-08-26 21:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L wrist and ankle pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with gout and ulcerative colitis, recent hospitalization from ___ for an ulcerative colitis flare and was subsequently discharged with 40 of PO prednisone daily. Now transferred from ___ for further evaluation of left wrist and left ankle pain. Patient states that he has been having excruciating left wrist pain for the last day and a half. No history of trauma. Does not feel like his typical gout flare which is mostly right-sided and in his great toe and ankle. Denies any recent medication changes. At ___, left upper extremity Doppler was unremarkable for DVT. Left upper extremity x-ray was also unremarkable for soft tissue or bony abnormalities. Reportedly attempted aspiration of patient's left wrist at OSH but was unsuccessful. Past Medical History: Ulcerative colitis X ___ years Gout Nephrolithiasis Cervical radiculopathy Social History: ___ Family History: Reports no significant family history of heart disease, stroke, diabetes, cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T 98.1, BP 154/81, HR 66, RR 18, SpO2 98/RA GENERAL: well-appearing male, lying in bed holding wrist gingerly, NAD. EYES: PERRL ENT: OP clear, normal dentition CV: RRR, S1+S2, no M/R/G RESP: CTAB, no W/R/C GI: non-distended, soft, non-tender. No masses. MSK: L wrist is without overlying erythema, swelling, or visible deformity. ROM is intact though very painful. ROM of fingers intact. Very TTP over dorsal and ventral aspects of wrists. L ankle is similarly without overlying erythema, swelling, or visible deformity. Very TTP over malleoli. SKIN: small pinpoint hole over dorsal L wrist (attempted arthocentesis). Scattered erythematous papules, 2mm, over chest, shoulders, and upper back. NEURO: sensation is grossly intact, moving all 4 extremities with purpose DISCHARGE PHYSICAL EXAM: Vitals: 97.9 134/81 64 16 96 Ra General: Well-appearing man, NAD, sitting up in bed HEENT: AT/NC, EOMI, no JVD, neck supple CV: RRR, s1+s2 normal, no m/g/r appreciated Pulm: CTAB Abd: +BS, non-tender, non-distended Ext: Pulses present, warm, no edema MSK: L forearm and wrist no longer wrapped in dressing, with ROM intact and less tender with motion of his wrist relative to prior. Ankle no longer erythematous with tenderness to ROM albeit not very limited Neuro: No motor/sensory deficits elicited Pertinent Results: ADMISSION LABS: ___ 06:05AM GLUCOSE-93 UREA N-16 CREAT-0.8 SODIUM-143 POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-36* ANION GAP-8* ___ 06:05AM CALCIUM-8.2* PHOSPHATE-4.1 MAGNESIUM-2.3 URIC ACID-6.5 ___ 06:05AM PTH-98* ___ 06:05AM WBC-9.8 RBC-4.51* HGB-13.0* HCT-40.2 MCV-89 MCH-28.8 MCHC-32.3 RDW-14.6 RDWSD-48.1* ___ 06:05AM PLT COUNT-190 ___ 07:50PM GLUCOSE-86 UREA N-13 CREAT-0.7 SODIUM-144 POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-30 ANION GAP-12 ___ 07:50PM estGFR-Using this ___ 07:50PM CRP-5.8* ___ 07:50PM WBC-9.9 RBC-4.62 HGB-13.3* HCT-41.1 MCV-89 MCH-28.8 MCHC-32.4 RDW-14.6 RDWSD-47.0* ___ 07:50PM NEUTS-49.4 ___ MONOS-9.4 EOS-3.1 BASOS-0.1 IM ___ AbsNeut-4.88 AbsLymp-3.72* AbsMono-0.93* AbsEos-0.31 AbsBaso-0.01 ___ 07:50PM PLT COUNT-194 ___ 07:50PM ___ PTT-24.1* ___ DISCHARGE LABS: ___ 05:25AM BLOOD WBC-15.7* RBC-4.57* Hgb-13.1* Hct-41.4 MCV-91 MCH-28.7 MCHC-31.6* RDW-14.6 RDWSD-48.1* Plt ___ ___ 05:25AM BLOOD Plt ___ ___ 05:25AM BLOOD Glucose-99 UreaN-19 Creat-0.8 Na-141 K-3.6 Cl-100 HCO3-30 AnGap-11 ___ 05:25AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 IMAGING: ___ L Ankle XR: No acute fracture or dislocation. ___ MRI L Arm/wrist: Scattered foci of subcutaneous edema most prominent in the radial aspect of the distal forearm. Tenosynovitis of the second extensor compartment tendons. Small ossific densities are noted adjacent the distal ulna which may be related to prior trauma. Dedicated radiographs of the wrist could be helpful for further evaluation. MICRO: ___: Blood Cx x2: PND Brief Hospital Course: ___ with gout and ulcerative colitis, recent hospitalization from ___ for an ulcerative colitis flare, presenting with 1 day history of severe left wrist and ankle pain believed to be a manifestation of tophacious gout precipitation. ACUTE ISSUES: #L WRIST PAIN: #L ANKLE PAIN: No bony or soft tissue abnormality on left wrist x-ray at ___ ___. L wrist not amenable to arthocentesis. Exam suggestive of extensor tenosynovitis. Presentation not felt to be consistent with septic arthritis per multiple consulting services. Differential included primarily gout vs IBD related arthritis, despite recent steroid course. His was CRP 5.8 (downtrending from prior) with a ESR WNL. Seen by hand who determined no acute need for surgical intervention. Seen by rheumatology who felt this was likely a manifestation of diffuse tophacious gout along his tendons in contrast to a crystal precipitation in his joint. He was pain controlled with Dilaudid during his stay which was tapered, and his pain improved significantly by the day of discharge. His allopurinol was increased to 400mg daily and started on lower dose colchicine 0.6mg daily. He obtained an MRI of his wrist/forearm which demonstrated L extensor tenosynovitis w/o notable tophi (final read not confirmed). Will follow-up with rheumatology. #ULCERATIVE COLITIS: s/p recent admission for flare, still on pred 40mg daily. Was due to see GI on ___ for planning of pred taper and determination of IBD status following bx. CRP/ESR reassuring. He was continued on prednisone 40 mg PO/NG DAILY, mesalamine ___ 2400 mg PO BID, and he receives Entyvio (vedolizumab) 300 mg injection EVERY 8 WEEKS as outpatient. He noted continued improvement in his symptoms, although he may experience some worsening diarrhea due to starting colchicine. #Vitamin D deficiency, PTH elevation: Likely primary vitamin D deficiency with secondary PTH elevation, will need further outpatient evaluation TRANSITIONAL ISSUES: #New medications: -Colchicine 0.6 mg PO/NG DAILY #Changed medications: -Allopurinol ___ mg PO DAILY --> Allopurinol ___ mg PO/NG DAILY []Please go to your PCP ___ []Please go to your rheumatology appointment []Recommend a uric acid level as an outpatient and titration of colchicine. []Please take 100mg allopurinol in addition to your 300mg at home to make a dose of 400mg daily []wbc was 15.7 and rising upon discharge. No s/s of infection. Please recheck as an outpatient as it was likely ___ prednisone. []Please follow-up final MRI L forearm read []Please recheck vitamin D and PTH and consider vitamin D repletion if remains low -Surrogate/emergency contact: ___, wife, ___ -Code Status: Full code (attempt resuscitation) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mesalamine ___ 2400 mg PO BID 2. PredniSONE 40 mg PO DAILY 3. Entyvio (vedolizumab) 300 mg injection EVERY 8 WEEKS 4. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm / pain 5. Allopurinol ___ mg PO DAILY Discharge Medications: 1. Colchicine 0.6 mg PO DAILY RX colchicine 0.6 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Allopurinol ___ mg PO DAILY RX allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm / pain 4. Entyvio (vedolizumab) 300 mg injection EVERY 8 WEEKS 5. Mesalamine ___ 2400 mg PO BID 6. PredniSONE 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Gout SECONDARY: Ulcerative colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. Why was I in the hospital? - You were hospitalized because you had a sudden increase in pain in your left arm and ankle following your recent discharge for your ulcerative colitis. What was done while I was in the hospital? - You were examined by the orthopedic (bone) doctors who did not find reasons to surgically operate. - You were also seen by the rheumatologic specialists who determined your new pains are likely from a different manifestation of your chronic gout disease. - Pictures were taken that showed you did not have any concerning injuries as fractures in your arm and wrist, but were consistent with the picture of gout. - You were kept on your prednisone medications for the ulcerative colitis and gout in addition to being started on further gout suppressing medications and increasing the dosage of medications aimed at helping to prevent a flare. Please stop your colchicine if your diarrhea becomes unbearable. What should I do when I go home? - It is very important that you take your medications as prescribed. - Please go to your scheduled appointment with your primary doctor and rheumatologist. - If you have fevers, excessive diarrhea, vomiting, coughing blood, please tell your primary doctor or go to the emergency room. Best wishes, Your ___ team Followup Instructions: ___
19828353-DS-6	19,828,353	27,761,875	DS	6	2196-12-02 00:00:00	2196-12-02 13:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Univasc / Losartan / oxcarbazepine Attending: ___. Chief Complaint: Hypernatremia, poor PO intake Major Surgical or Invasive Procedure: ___ line placement History of Present Illness: Ms. ___ is a ___ woman with a history of seizures, prior stroke, and an unspecified major neurocognitive disorder who presented to the ED from ___ nursing home with agitation. Per RN at ___ she had been increasingly agitated over the last few days and had had poor PO intake, they did labs at that point which showed a sodium level of 163 so she was referred to the ED. She was found to have a UTI by culture at the ___. In discussing ___ baseline mental status ___ daughter says she is often very somnolent and is rarely oriented at all but can communicate in short sentences. ___ RN at the ___ says she is more alert and interactive with staff and is sometimes oriented. She does at baseline have a lot of pain from arthritis in ___ hip and knee. ___ pain regimen had been recently increased of tramadol 25mg TID increased to 50mg TID. She had been on standing Tylenol and motrin was added 1 day ago. In ED initial VS: Temp 97.7, HR 74, BP 100/76, RR 16, SaO2 97% RA Exam: Normal with the exception of a Stage 3 wound near ___ gluteal cleft Patient was given: 500 mL NS, 1L ___ @ 150/hr; Ceftriaxone 1g IV x1 Imaging notable for: CXR Clear. Consults: None VS prior to transfer: HR 62, BP 111/98, RR16, SaO2 98% RA On arrival to the MICU, patient was initially agitated and then became more calm and fell asleep but was easily arouseable. Past Medical History: - ATYPICAL CHEST PAIN - RESTRICTIVE LUNG DISEASE - HBV CORE AB +, SAB+ - HYPERTENSION - LEFT SHOULDER RTC SYNDROME W/OA - LT. KNEE EFFUSION - SINUSITIS/ALLERGIC RHINITIS - SEIZURE DISORDER - PRIOR STROKE - DEMENTIA Social History: ___ Family History: Unable to obtain ___ mental status Physical Exam: ========================= ADMISSION PHYSICAL EXAM ========================= VITALS: Afebrile HR 62, BP 161/58, RR 16, SaO2 97%RA GENERAL: Sleepy but easy to wake, oriented x1 , no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear NECK: supple, JVP not elevated LUNGS: Clear to auscultation bilaterally anteriorly CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Well healed midline scar, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Healed ulcer on coccyx NEURO: oriented x1, moving bilateral UE and right toes. Sensation intact. EOMI, PERRL. ========================= DISCHARGE PHYSICAL EXAM ========================= VITALS: AVSS GENERAL: Alert, sleeping initially, lying in bed EYES: Anicteric, pupils equally round; no conjunctival injection or signs of scleritis; bilateral arcus ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: + BS, soft, NT, ND, no HSM GU: no CVAT appreciated, no foley MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs EXT: R-sided PICC, c/d/i SKIN: No rashes or ulcerations noted NEURO: AOx1 (person) not cooperative for full neuro exam, but CN grossly intact, moving all extremities spontaneously MSK: R.knee without erythema, no passive tenderness on ROM, moderate effusion Pertinent Results: ================ ADMISSION LABS ================ ___ 06:45PM BLOOD WBC-8.1# RBC-4.36 Hgb-12.8 Hct-43.8 MCV-101# MCH-29.4 MCHC-29.2# RDW-14.9 RDWSD-55.5* Plt ___ ___ 06:45PM BLOOD Neuts-64.7 ___ Monos-5.2 Eos-1.2 Baso-0.2 Im ___ AbsNeut-5.27# AbsLymp-2.30 AbsMono-0.42 AbsEos-0.10 AbsBaso-0.02 ___ 06:45PM BLOOD Plt ___ ___ 06:45PM BLOOD Glucose-93 UreaN-40* Creat-0.8 Na-164* K-3.6 Cl-117* HCO3-33* AnGap-17 ___ 06:45PM BLOOD Calcium-9.6 Phos-4.0 Mg-2.9* ___ 07:03PM BLOOD Lactate-1.8 ___ 05:30PM URINE Blood-TR* Nitrite-POS* Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 05:30PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 05:30PM URINE RBC-7* WBC->182* Bacteri-MANY* Yeast-NONE Epi-3 ================ DISCHARGE LABS ================ ___ 06:45AM BLOOD WBC-6.9 RBC-3.35* Hgb-10.1* Hct-31.2* MCV-93 MCH-30.1 MCHC-32.4 RDW-14.1 RDWSD-47.6* Plt ___ ___ 05:05AM BLOOD Glucose-92 UreaN-9 Creat-0.6 Na-144 K-3.5 Cl-103 HCO3-29 AnGap-12 ___ 06:10AM BLOOD Na-143 ___ 12:01PM BLOOD Na-145 ___ 03:11AM BLOOD ALT-9 AST-14 AlkPhos-51 TotBili-0.3 ___ 05:05AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.2 ___ 06:45AM BLOOD calTIBC-185* Ferritn-348* TRF-142* Brief Hospital Course: This is an ___ with a history of seizures, prior stroke, and an unspecified major neurocognitive disorder with resulting advanced dementia who presented to the ED from ___ nursing home with AMS and hypernatremia in the context of a urinary tract infection. ___ course has been notable for correction of hypernatremia, improvement in MS to baseline, treatment of UTI, and a change in ___ goals of care to hospice. # Acute toxic metabolic encephalopathy superimposed on # Advanced dementia: Advanced baseline dementia, which likely contributed to initial presentation. Acute alteration in MS on admission, but improved to near-baseline with treatment of issues as below. She has had some difficulty with calling out and occasional flares of agitation when perturbed, but recently has been very pleasant and calm, likely due to supportive environment and single room. Some waxing and waning over the past 48 hours, with signs of hypoactive delirium intermittently. Given longstanding severe issues, palliative care was involved and meetings with HCP undertaken. Patient is now DNR/DNI/DNH, no escalation of care, with plan for transfer to hospice. - Continuing dementia, mood, and sleep medications as listed below - Formal speech and swallow eval recs for puree solids and thin liquids. Meds crushed in puree. # Hypernatremia and # Dehydration: Likely secondary to inadequate PO intake in setting of advanced dementia and UTI. Now resolved with return in mental status to baseline. Cleared by S/S for pureed solid diet, thin liquids. Intermittently refuses meals and medications. Artificial nutrition against goals of care. - Continue to encourage PO as much as able, purees/thins # Ascending UTI: Klebsiella growing at cultures at SNF (amp R), concerning for ascending infection in setting of AMS. Mental status now back to baseline with correction of dehydration and treatment of UTI. UCX here with mixed flora. S/p 5d course of ceftriaxone, finished ___. # Knee pain and effusion likely due to # Osteoarthritis: No signs of infection, pain improved with treatment with tramadol and Tylenol along with lidocaine patch. - Continue these medications, as outlined below # Seizure disorder: Stable without signs of active seizures. She has intermittently refused ___ medications. - Continue home medications, as outlined below # Normocytic anemia: Hct 31.5 from 43.8 on admission. Possibly dilutional plus blood draws. No e/o melena/hematochezia or hematuria. Iron studies c/w ACD. No signs of active bleeding thus far. # HLD # GERD # Prior stroke: Stable without symptoms. Stopped these home medications given change in goals of care and report that she feels like she's taking too many medications. Code status is DNR/DNI/Do Not Rehospitalize, per MOLST. Billing: >30 minutes spent coordinating discharge to facility Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. TraZODone 25 mg PO QAM 3. Aspirin 81 mg PO DAILY 4. Divalproex Sod. Sprinkles 500 mg PO DAILY 5. TraZODone 50 mg PO QHS 6. Calcium Carbonate 500 mg PO BID 7. Divalproex Sod. Sprinkles 750 mg PO BID 8. LevETIRAcetam 500 mg PO BID 9. Memantine 10 mg PO BID 10. Sodium Chloride Nasal ___ SPRY NU BID 11. Senna 8.6 mg PO BID 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 13. Donepezil 5 mg PO QHS 14. Atorvastatin 20 mg PO QPM 15. melatonin 3 mg oral Q72H 16. Acetaminophen 500 mg PO Q8H 17. TraMADol 50 mg PO TID 18. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q1H:PRN Dry or itchy eye 2. Docusate Sodium 100 mg PO BID 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. Senna 17.2 mg PO BID 6. TraMADol ___ mg PO Q6H:PRN Pain - Moderate 7. TraZODone 25 mg PO QHS:PRN sleep 8. Divalproex Sod. Sprinkles 500 mg PO DAILY 9. Divalproex Sod. Sprinkles 750 mg PO BID 10. Donepezil 5 mg PO QHS 11. LevETIRAcetam 500 mg PO BID 12. melatonin 3 mg oral Q72H 13. Memantine 10 mg PO BID 14. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Advanced dementia Toxic/metabolic encephalopathy Hypernatremia, dehydration Urinary tract infection Seizure disorder Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for confusion. You were found to have a urinary tract infection and elevated blood sodium levels. You improved with IV fluids and antibiotics. After further conversation, it was decided to focus your care on comfort. You are being discharged to a facility for further care. Followup Instructions: ___
19828387-DS-18	19,828,387	29,376,767	DS	18	2179-08-21 00:00:00	2179-08-21 22:05:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine Attending: ___. Chief Complaint: Nausea/ Vomiting; Diarrhea Major Surgical or Invasive Procedure: Diagnostic/ Therapeutic Paracentesis History of Present Illness: Ms. ___ is a ___ female with celiac disease and advanced peritoneal cancer s/p 3 cycles of neoadjuvant chemotherapy, surgical cytoreduction, and 3 cycles of adjuvant chemotherapy who presents with abdominal pain and nausea/vomiting. She reports that over the past ___ weeks, she has noted progressively increasing abdominal pressure and distention. She then went to a local restaurant in ___ on ___ for a special mushroom themed dinner. She had a large dinner and also drank more wine than usual. That evening she developed nausea. The following day on ___ she had many non-bloody watery bowel movements. On day of admission she had continued nausea and 2 episodes of non-bloody emesis. She notes that today her diarrhea is much improved and she only had 1 small loose stool but no longer watery. She came to the hospital today for a lab check which was notable for rising CA-125. The remainder of her labs were unremarkable. She then went home but came back later in the day for an CT torso. Her outpatient team was called by Radiology with concern for possible bowel obstruction and she was referred to the ED. On arrival to the ED, initial vitals were 97.0 97 135/75 16 99% RA. Exam was notable for mildly distended non-tender abdomen. No labs obtained. No imaging obtained. Patient was given IVF. Prior to transfer vitals were 97.2 88 128/78 18 100% RA. On arrival to the floor, patient denies any pain. She notes occasional dizziness and neuropathy in her feet. She denies fevers/chills, night sweats, headache, vision changes, weakness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: Ms. ___ was found to have progressive ascites on a recent trip to ___. She tells us that she was seen by emergency department while there, and they performed a paracentesis. She showed us her pathology report from ___, which confirmed the presence of malignant cells, favoring adenocarcinoma. They were CK 7 positive, CK20 negative, CDX 2 negative, GATA 3 negative, CA 125 positive. She underwent a CT of the abdomen on ___. This showed a large amount of abdominal pelvic ascites. There was also bilateral adnexal round soft tissue structures, and diffuse thickening of the peritoneum. A segment VII hepatic hemangioma was noted. CT imaging of the chest on ___ showed multiple bilateral pulmonary nodules measuring up to 3 mm. A small right pleural effusion with compressive atelectasis appreciated. - ___: C1D1 Carboplatin AUC 6, Taxol 175 mg/m2, Bevacizumab 15 mg/kg - ___: C2D1 ___ AUC 6/Taxol 175 mg/m2, bevacizumab 15 mg/kg - ___: C3D1 ___ AUC 6/Taxol 175 mg/m2 - ___: Surgical cytoreduction at ___ - ___: C4D1 ___ AUC 6/Taxol 175mg/m2 (bevacizumab held) - ___: C5D1 ___ AUC 6/Taxol 175mg/m2/bevacizumab 15mg/kg - ___: C6D1 ___ AUC 6/Taxol 175mg/m2 bevacizumab 15mg/kg PAST MEDICAL HISTORY: - Peritoneal Cancer, as above - Celiac Disease Social History: ___ Family History: FAMILY HISTORY: She has no family history of breast or ovarian cancer. Her son was treated for testicular cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.8, BP 113/72, HR 79, RR 18, O2 sat 99% RA. GENERAL: Very pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, no murmurs. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally. ABD: Soft, mild diffuse tenderness to palpation, mildly distended, positive bowel sounds,. EXT: Warm, well perfused, no lower extremity edema. NEURO: A&Ox3, good attention and linear thought, gross strength and sensation intact. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM VS: t97.3 bp113/75hr73rr20 o2sat98 GENERAL: Very pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, no murmurs. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally. ABD: Soft, mild diffuse tenderness to palpation, mildly distended, positive bowel sounds,. EXT: Warm, well perfused, no lower extremity edema. NEURO: A&Ox3, good attention and linear thought, gross strength and sensation intact. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS: ___ 09:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 09:25AM WBC-5.5 RBC-4.06 HGB-13.1 HCT-40.3 MCV-99* MCH-32.3* MCHC-32.5 RDW-13.4 RDWSD-48.9* ___ 09:25AM UREA N-10 CREAT-0.7 SODIUM-137 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-13 ___ 09:25AM ALT(SGPT)-8 AST(SGOT)-18 ALK PHOS-61 TOT BILI-0.5 ___ 09:25AM ALBUMIN-4.4 PHOSPHATE-3.9 MAGNESIUM-1.9 DISCHARGE LABS: ___ 06:30AM BLOOD WBC-4.5 RBC-3.58* Hgb-11.5 Hct-35.5 MCV-99* MCH-32.1* MCHC-32.4 RDW-13.3 RDWSD-48.5* Plt ___ ___ 06:30AM BLOOD Glucose-71 UreaN-11 Creat-0.7 Na-140 K-4.3 Cl-101 HCO3-25 AnGap-14 ___ 06:30AM BLOOD ALT-8 AST-13 LD(LDH)-139 AlkPhos-47 TotBili-0.7 ___ 06:30AM BLOOD Albumin-3.6 Calcium-9.3 Phos-4.2 Mg-1.8 Brief Hospital Course: Ms. ___ is a ___ woman with celiac disease and advanced peritoneal cancer s/p 3 cycles of neoadjuvant chemotherapy, surgical cytoreduction, and 3 cycles of adjuvant chemotherapy who presented with with abdominal pain and nausea/vomiting. She had an early small bowel obstruction on imaging which is thought to be the cause of nausea/vomiting/abdominal pain. TRANSITIONAL ISSUES: [] CA-125 marker level elevated to 76 here, oncologist to followup on future treatments [] Oncologist to follow up on peritoneal fluid studies (no growth to date) [] PCP to follow up on celiac disease, possible relation to diarrhea she had before presentation ACUTE ISSUES =========== # Cancer-Related Abdominal Pain # Nausea/Vomiting Ms. ___ symptoms were likely to due to recurrence in malignancy which resulted in an early/developing small bowel obstruction (seen on CT A/P ___. On CT, her small bowel also showed evidence of possible enteritis. Her physical exam was benign and she appeared well throughout the hospitalization. She was treated with Tylenol for pain and Zofran for nausea. She was kept NPO initially, and her diet was advanced before discharge. On discharge her nausea was well controlled and she could tolerate PO intake (regular diet). #Ascites The etiology of this is likely malignant, as she has had a history of this in the past. She stated that over the last 3 weeks she has felt more distended and had increasing abdominal pain. CT scan showed that she had moderate interval increase in her ascites. She received a diagnostic/ theraputic paracentesis. Peritoneal fluid studies were sent and showed no growth to date at time of discharge. She had no complications from the procedure, and on discharge her abdominal pain improved. # Diarrhea: She reported non bloody, watery diarrhea of 1 day but had resolution of her loose stools after one day. An abdominal CT showed small bowel wall edema and hyperemia concerning for enteritis. The diarrhea significantly improved and was likely related to gastroenteritis. CHRONIC ISSUES ============= # Peritoneal Cancer: She was in remission since the ___, however, she had a rising CA-125 (76 here) and evidence of disease recurrence on imaging. Her primary oncologist, Dr. ___, was informed of her stay in the hospital. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 0.5 mg PO QHS:PRN anxiety/insomnia 2. Multivitamins 1 TAB PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 3. Cyanocobalamin 1000 mcg PO DAILY 4. LORazepam 0.5 mg PO QHS:PRN anxiety/insomnia 5. Multivitamins 1 TAB PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: CANCER RELATED NAUSEA/ VOMITING Secondary Diagnosis: Peritoneal Cancer Celiac Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were admitted for nausea/vomiting and diarrhea. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your diarrhea resolved without much intervention. - You were found to have an early small bowel obstruction on imaging, which is the likely process which caused your nausea. - Your were able to tolerate food with the help of some nausea medications, and you were discharged on a regular diet. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19828393-DS-6	19,828,393	23,311,511	DS	6	2135-06-10 00:00:00	2135-06-10 22:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: Abdominal Pain, N/V Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M with PMHx of HTN, DM, afib on coumadin, CAD s/p PCI, ___, colon CA, with recent ERCP with biliary and PD stent placement and then repeat ERCP earlier this week with stent pull. During repeat ERCP, he was found to have a large stone remaining in the remnant GB vs cystic duct which was unable to be removed. He did well post-procedurally and was discharged home 2 days ago. However, yesterday evening, approximately 30 minutes after eating, the patient developed recurrent diaphoresis, nausea, vomiting, diarrhea, and epigastric pain. He reports that symptoms are identical to the prior symptoms which prompted his initial ERCP. He presented OSH ED and was transferred here for eval. ED Course: Initial VS: 97 86 155/77 16 95% ra Pain ___ Labs significant for mild transaminitis. Imaging: CXR largely unremarkable (see report below) Meds given: zofran 4 mg IV, morphine 5 mg IV (in addition to protonix, morphine, and zofran given at ___) VS prior to transfer: 97.5 75 128/71 18 95% RA Pain ___ On arrival to the floor, the patient reports that he feels much better after pain given in the ED. Currently, no nausea. Only some mild epigastric discomfort. ROS: As above. Pt also reports some DOE which is chronic as well as neuropathy in his feet which is chronic. Denies headache, lightheadedness, dizziness, sore throat, sinus congestion, chest pain, heart palpitations, shortness of breath, cough, constipation, urinary symptoms, muscle or joint pains, skin rash. The remainder of the ROS was negative. Past Medical History: HTN DM HLD CAD s/p PCI Chronic Diastolic CHF Colon cancer Afib on coumadin Mitral valve replacement BPH Gastritis Social History: ___ Family History: father with DM and HTN Physical Exam: Admission Exam: VS - 98.0 134/66 85 16 95%RA Pain ___ GEN - Alert, NAD HEENT - NC/AT, no scleral icterus NECK - Supple CV - Irreg, no m/r/g appreciated RESP - CTA B ABD - S/ND, BS present, mild epigastric TTP without rebound or guarding EXT - chronic venous stasis changes on legs, trace pitting edema bilaterally SKIN - chronic venous stasis changes as above, no other rashes appreciated, non-icteric NEURO - non-focal PSYCH - calm, appropriate Discharge Exam: Vital Signs: 98.2 121/69 71 18 95%RA Glucose: ___ GEN: Alert, NAD HEENT: NC/AT CV: irreg irreg, no m/r/g PULM: CTA B GI: S/ND, BS present, mild ttp in the epigastrum, no rebound or guarding NEURO: Non-focal Pertinent Results: Admission Labs: ___ 02:25AM BLOOD WBC-4.8 RBC-4.81 Hgb-13.0* Hct-41.5 MCV-86 MCH-27.0 MCHC-31.3 RDW-14.2 Plt Ct-93* ___ 02:25AM BLOOD Neuts-88.4* Lymphs-6.7* Monos-3.1 Eos-0.9 Baso-0.9 ___ 02:25AM BLOOD ___ PTT-39.8* ___ ___ 02:25AM BLOOD Glucose-262* UreaN-9 Creat-1.0 Na-136 K-4.5 Cl-103 HCO3-23 AnGap-15 ___ 02:25AM BLOOD ALT-157* AST-108* AlkPhos-42 TotBili-0.6 ___ 02:25AM BLOOD Lipase-43 ___ 02:25AM BLOOD cTropnT-0 ___ 02:25AM BLOOD Albumin-4.2 Calcium-8.8 Phos-4.0 Mg-1.5* ___ 02:42AM BLOOD Lactate-1.4 Discharge Labs: ___ 06:25AM BLOOD WBC-4.5 RBC-4.56* Hgb-12.8* Hct-39.2* MCV-86 MCH-28.1 MCHC-32.7 RDW-14.2 Plt ___ ___ 06:25AM BLOOD Glucose-173* UreaN-9 Creat-1.2 Na-138 K-4.5 Cl-102 HCO3-27 AnGap-14 ___ 06:25AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.0 ___ 06:15AM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:15AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 06:15AM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 ___ 06:15AM URINE CastHy-5* Blood Cx x 2 PENDING at the time of discharge with no growth to date CXR - Mild left baisilar opacities likely representing atelectasis, though an early overlying infectious process must be excluded in proper clinical setting. Minimal pulmonary edema. ECG - Atrial fibrillation with variable A-V conduction. No previous tracing available for comparison. Brief Hospital Course: ___ y/o M with PMHx of HTN, DM, afib on coumadin, CAD s/p PCI, dCHF, colon CA, with recent ERCP with biliary and PD stent placement and then repeat ERCP earlier this week with stent pull. During repeat ERCP, he was found to have a large stone remaining in the remnant GB vs cystic duct which was unable to be removed. Returned to ___ with recurrent N/V and abdominal pain, which quickly resolved. He was seen by surgery, who recommended outpatient follow-up for consideration of surgial stone removal. At the time of discharge, pt only had mild abdominal tenderness to deep palpation and was tolerating regular diet with no nausea or vomiting. Of note, coumadin had been held for prior ERCP. Was restarted on ___, INR should be rechecked on ___. This was communicated with pt's cardiologist's office prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. U-500 30 Units Breakfast U-500 30 Units Dinner Insulin SC Sliding Scale using UNK Insulin 2. Digoxin 0.125 mg PO DAILY 3. Diltiazem Extended-Release 120 mg PO DAILY 4. Lisinopril 10 mg PO BID 5. Metoprolol Succinate XL 150 mg PO DAILY 6. Omeprazole 20 mg PO BID 7. Simvastatin 40 mg PO DAILY 8. Tamsulosin 0.4 mg PO HS 9. Furosemide 60 mg PO BID 10. Niaspan Extended-Release (niacin) 1,000 mg oral HS 11. Potassium Chloride 20 mEq PO DAILY 12. Warfarin 8 mg PO 5X/WEEK (___) 13. Warfarin 6 mg PO 2X/WEEK (___) Discharge Medications: 1. Digoxin 0.125 mg PO DAILY 2. Diltiazem Extended-Release 120 mg PO DAILY 3. U-500 30 Units Breakfast U-500 30 Units Dinner 4. Lisinopril 10 mg PO BID 5. Metoprolol Succinate XL 150 mg PO DAILY 6. Tamsulosin 0.4 mg PO HS 7. Warfarin 8 mg PO 5X/WEEK (___) 8. Furosemide 60 mg PO BID 9. Niaspan Extended-Release (niacin) 1,000 mg oral HS 10. Potassium Chloride 20 mEq PO DAILY 11. Simvastatin 40 mg PO DAILY 12. Warfarin 6 mg PO 2X/WEEK (___) 13. Sucralfate 1 gm PO QID RX sucralfate 1 gram 1 tablet(s) by mouth 4 times a day Disp #120 Tablet Refills:*0 14. Omeprazole 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Choledocholithiasis Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with recurrent nausea, vomiting, and abdominal pain after your recent ERCP, likely related to your known gallstone. You were seen by the surgeons, who recommended that you follow-up with them as an outpatient to plan for surgical removal of your gallstone. You were restarted on your coumadin today (___). You should followup with your cardiologist to have your INR checked on ___. It was a pleasure taking part in your medical care. Followup Instructions: ___
19828622-DS-14	19,828,622	28,816,282	DS	14	2146-02-18 00:00:00	2146-02-21 23:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Laparascopic Appendectomy History of Present Illness: Mrs. ___ is a ___ year old woman who was in her usual state of health until last night, when she developed low abdominal pain as she was preparing for bed. Patient reports she slept poorly throughout the night because she kept having to get up repeatedly to urinate. She had one episode of dysuria. Denies hematuria. She called her PCP ___ 5am who referred her to an urgent care clinic. Her U/A at urgent care was negative and out of concern for her abdominal exam, the patient was referred to the ___ ED for further evaluation. She otherwise denies recent fevers, chills, nausea, vomiting, or diarrhea. Her pain started and has remained in the B/L lower quadrants, R>L. Past Medical History: PMH: none PSH: foot surgery Social History: ___ Family History: non-contributory Physical Exam: GEN - NAD, awake/alert HEENT - NCAT, EOMI, no scleral icterus, dry mucous membranes CV - RRR PULM - no resp distress ABD - soft, nondistended, mild b/l quadrant TTP without rebound or guarding; no palpable masses or hernias EXTREM - warm, well-perfused; no C/C/E Pertinent Results: ___ 12:10PM BLOOD WBC-11.1* RBC-4.52 Hgb-13.5 Hct-40.0 MCV-88 MCH-29.8 MCHC-33.7 RDW-12.9 Plt ___ ___ 12:10PM BLOOD Neuts-79.6* Lymphs-16.2* Monos-3.4 Eos-0.6 Baso-0.2 ___ 12:10PM BLOOD Glucose-98 UreaN-10 Creat-0.9 Na-139 K-3.5 Cl-101 HCO3-23 AnGap-19 Brief Hospital Course: The patient was admitted to the Acute Care Surgery service on ___ and had a laparoscopic appendectomy. The patient tolerated the procedure well. Neuro: Post-operatively, the patient received Dilaudid IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#1. Intake and output were closely monitored. ID: Post-operatively, the patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: OCPs Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth q4-6 hours Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID Take to help with constipation caused by oxycodone RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #20 Capsule Refills:0 4. Senna 8.6 mg PO BID:PRN constipation Take to help with constipation due to oxycodone RX sennosides [___] 8.6 mg 1 tab by mouth twice a day Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute Appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were evaluated in the Emergency Department for abdominal pain and found to have acute appendicitis. You underwent laparascopic appendectomy and did well following the surgery. Return to the ER if: If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * You may take a shower after 24 hours from your surgery have passed, but do not bathe or go swimming until instructed by your surgeon. * No strenuous activity until instructed by your surgeon. Followup Instructions: ___
19828866-DS-20	19,828,866	23,506,167	DS	20	2171-03-18 00:00:00	2171-03-18 20:03:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ w/multiple admissions for COPD exacerbations and alcohol withdrawal presents with SOB since yesterday. She reports her sob started gradually and is associated with wheezing. She also reports a nonproductive cough and f/c over the past week. She also reports pleuritic chest pain and diarrhea over the past two days. She also endorses palpitations and shakes and reports her last drink was 6 am on ___. She also notes increased ___ and abdominal edema. She continues to smoke, but reports wanting to quit smoking and drinking alcohol. She also reports darkening of the skin on her hands. She endorses her usual depression, but denies suicidal or homicidal ideation. Upon review of OMR, she was last admitted here ___ for sob and was found to have COPD exacerbation secondary to cigarette smoking. She presented with diffuse expiratory wheezes and prolong expiratory phase. She was continued on previous treatment from her previous admission on ___ with azithromycin, prednisone, and ipratroprium/albuterol nebulizers. By hospital day two the patient no longer was requiring supplemental oxygen and her lungs were clear to auscultation bilaterally. On ___: The patient requested to leave the hospital temporarily such that she could go outside and smoke cigarettes. The medical team urged the patient that she should stay and continue to receive treatment for her alcohol withdrawal as well as her COPD. She had a nicotine patch. She was offered nicotine gums as well. The patient reported that she could not stay in the hospital. The patient was alerted that it was strongly against medical advice for her to leave as she could have an alcohol withdrawal seizure or worsening of her COPD. She acknowledged these risks, but said that she had to go. Given that the patient showed clear understanding of the risks and benefits involved in receiving treatment and formal psychiatric evaluation indicated that the patient had capacity to make her own decisions and was not ___, she left AMA before receiving and discharge paperwork. In ER: VS: 99.6 89 173/87 28 100% 10L NRB PX: axox3; #18 Right FA; RR ~30; rales bilaterally R>L; some apical wheezing bilaterally. 2+ pitting edema bilat ___ Studies: HCT 35.1, WBC 3.4, N:70.6 L:19.9 M:8.4 E:0.5 Bas:0.6; pH 7.52, pCO2 36, pO2 64, HCO3 30, BaseXS 5 VBG didn't show any sign of CO2 retention. CXR: consistent with COPD versus CHF. Fluids given: None Meds given: Azithromycin for COPD exacerbation; nebs x 2 with + relief, medicated with solumedrol 125mg and magnesium 2gm (due to daily etoh) medciated with lorazepam 2mg IV x 2, last at 0050 for CIWA > 10; BNP and troponin negative. Consults called: None VS prior to transfer to the floor: 98.8 16 146/68 100%2L 24 Review of Systems: (+) Per HPI (-) Denies night sweats, recent weight loss. Denies visual changes, sinus tenderness, neck stiffness, rhinorrhea, sore throat or dysphagia. Denies orthopnea. Denies nausea, vomiting, heartburn, constipation, BRBPR, melena. No dysuria, urinary frequency. Denies myalgias. No numbness/tingling or muscle weakness in extremities. All other review of systems negative. Past Medical History: - Alcohol abuse (more than 1 gallon vodka daily) - COPD - Hepatitis C (reportedly presently discussing potential treatment options) - Hypertension - S/p Cesarean section x 3 - Cirrhosis (diagnosed radiologically) Social History: ___ Family History: Her father is alive and is an alcoholic and her mother is alive and has AFIB. Physical Exam: VS: 98.4 174/94 97 18 98% on 2L; ___ pain GEN: No apparent distress; disheveled HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Bilateral wheezes and rales in lower bases; no crackles/rhonchi GI: +distention; no guarding/rebound; normal bowel sounds EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, ___ motor function globally; + tremor DERM: Hyperpigmented dorsal hands bilaterally Discharge Exam: VS: Tm Afebrile Tc BP 110s-130s/70s HR 70-90s RR ___ SaO2 95-98% RA GENERAL: [x] NAD [] Uncomfortable. Eyes: [x] anicteric [] PERRL. ENT: [x] MMM [] Oropharynx clear [] Hard of hearing. No tongue tremor. NECK: [] No LAD [] JVP: ___: [] RRR [] nl s1 s2 [] no MRG [x] no edema. LUNGS: [] No rales [] No wheeze [] comfortable. scattered wheeze, improved from yesterday. ABDOMEN: [x] Soft [x]nontender []bowel sounds present []No hepatosplenomegaly. SKIN: []No rashes [x]warm [x]dry [] decubitus ulcers: scattered spider angiomas. LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD NEURO: [x] Oriented x3 [x] Fluent speech. No tremor or asterixis Psych: [x] Alert [x] Calm [] Mood/Affect: Pertinent Results: Admission Labs: ___ 10:39PM ___ PO2-64* PCO2-36 PH-7.52* TOTAL CO2-30 BASE XS-5 ___ 10:35PM GLUCOSE-134* UREA N-7 CREAT-0.6 SODIUM-138 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-24 ANION GAP-19 ___ 10:35PM cTropnT-<0.01 ___ 10:35PM proBNP-16 ___ 10:35PM WBC-3.4* RBC-3.62* HGB-11.3* HCT-35.1* MCV-97 MCH-31.2 MCHC-32.1 RDW-17.8* ___ 10:35PM NEUTS-70.6* ___ MONOS-8.4 EOS-0.5 BASOS-0.6 ___ 10:35PM PLT COUNT-138* ___ 10:35PM ___ PTT-28.3 ___ Imaging: ___ Radiology CHEST (PORTABLE AP): IMPRESSION: No evidence of acute disease. RUQUS IMPRESSION: Limited examination. Patent portal vein. No evidence of gallstones or cholecystitis, and no biliary ductal dilation. ___ CXR:IMPRESSION: No signs for acute cardiopulmonary process. Discharge/Notable Labs: ___ 10:45AM BLOOD WBC-3.0* RBC-3.78* Hgb-11.9* Hct-38.3 MCV-101* MCH-31.5 MCHC-31.0 RDW-17.0* Plt ___ ___ 06:15AM BLOOD Glucose-97 UreaN-10 Creat-0.5 Na-137 K-3.7 Cl-102 HCO3-30 AnGap-9 ___ 06:15AM BLOOD ALT-63* AST-156* AlkPhos-363* Studies pending on discharge: None Brief Hospital Course: ___ homeless F with alcohol dependence, hepatitis C, and COPD admitted with alcohol withdrawal and COPD exacerbation #Alcohol dependence/Alcohol withdrawal: The patient noted that she drinks several litres of vodka per day. Her last reported drink was 0600 on ___. She denies having seizures in the past. The patient was placed on a CIWA scale and required frequent doses of benzodiazepines. She was counseled on the importance of quitting drinking. #Alcoholic hepatitis/Possible cirrhosis: Patient presented with worsening of her transaminitis with improvement in her LFTs during admission. She did not meet criteria for treatment with steroids. A RUQUS showed patent portal vein but was limited by body habitus. #Chronic Obstructive Pulmonary Disease exacerbation: Patient endorsed increased cough, shortness of breath and had an oxygen requirement and was diffusely wheezy on exam without infiltrate on CXR. She was treated with prednisone 20mg po daily x5 days as well as azithromycin x5 days with improvement in her symptoms. #. Bilateral lower extremity edema: Chronic. Most likely related to mild volume overload and venous stasis as well as medication noncompliance. The patient was continued furosemide 40mg per "home dosing" with reduction in lower extremity edema. Patient was discharged on Lasix 20mg po daily given her weight loss on 40mg po. She did not have evidence of ascites on imaging. . #CODE: Full code #Disposition: Patient was discharged "home". Placement at ___ ___ could not be arranged, but the patient stated that she would be staying in a shelter. She was with her husband on discharge. Medications on Admission: (Home medication list reconciled on this admission) furosemide 40 mg 1 po daily lopressor 25 mg po BID flovent inh daily albuterol inh 2 puffs q6h prn sob neurontin 600 mg TID motrin 600 mg po prn arthritic knee pain Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 4. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for shortness of breath/wheeze. Disp:1 inhaler Refills:2 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath/wheeze. Disp:1 inhaler Refills:2 6. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:2 Tablet(s) Refills:0 9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): Do not smoke tobacco while using this patch. Disp:30 Patch 24 hr(s) Refills:2 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: COPD exacerbation alcohol withdrawal alcoholic hepatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with worsening shortness of breath, cough, and signs of alcohol withdrawal. You were treated for an exacerbation of your COPD and should continue your azithromycin (antibiotic) and prednisone as prescribed for the full course. You should also take both your prescribed inhalers as prescribed if you have shortness of breath, wheezing, or significant coughing that wil not resolve. You were also found to have alcoholic hepatitis and alcohol withdrawal which improved during your hospitalization. Since you already have significant damage to your liver it is very important that you make efforts to quit drinking as alcohol can lead to liver failure and liver cancer. Please your PCP after discharge and make an appointment to see a GI/Liver specialist. Please call your doctor if you experience any worsening of your breathing, develop fevers or chills, have increase in your sputum production, or notice any swelling of your abdomen or legs. Followup Instructions: ___
19828866-DS-21	19,828,866	24,462,311	DS	21	2171-05-04 00:00:00	2171-05-04 16:06:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: SOB subjective fevers/chils N/V melena fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with EtOH cirrhosis who presented to the ED 5 days after stopping EtOH with fatigue, shortness of breath. She and her husband are homeless. Of note, she was admitted ___ for COPD exacerbation and EtOH withdrawal. 5 days ago, was seen in ED b/c she drank to the point of passing out and when she woke up she had bites on her lower abdomen, possibly from rats. The area was cleaned, she was given tetanus shot. Since then, she cut her drinking down from 3bottles vodka/d to ___ bottle vodka/day - has been lethargic (sleeing all day for the last ___ days), with N/V and dry heaves (no blood or bile in vomitus) with associated ___ belly pain and melena. Notes worsening shortness of breath especially with exertion (can't walk more than 5 steps) with an associated dry cough. he also complains for subjective fevers and chills for the last 5 days. She has been taking her Lasix (dose was halved at last hospitalization), but has not been her Metoprolol and has missed her inhalers recently due to fatigue. The patient denies chest pain, neck/arm pain, constipation. She has no history of withdrawl seizures or DTs. Complains of a frontal headache since yesterday which she normally gets when she withdraws, and a hoarse voice. Patient went through menopause ___ years ago. In the ED initial vitals were: 99.3 112 160/94 16 97%. Abdominal wound not felt to be infected. She was diffusely wheezy on exam. Labs were notable for no leukocytosis, Hct 31.9 (baseline ~35), K 3.1, and transaminitis beyond her baseline with ALT 73, AST 367, TBili 7.6. EtOH level was 171. RUQ U/S was performed. She was given Albuterol/Ipratropium nebs x2, PredniSONE 60 mg, and Azithromycin 500mg for COPD flare. Received Ibuprofen 600mg for pain. Diazepam 5mg PO to prevent withdrawal. Also got Potassium 40mEq PO. She was admitted to Medicine for further management. VS prior to transfer were 98.5, HR 92, BP 118/72, O2 sat 97%, RR ___. On arrival to the floor, she is sleepy and complaining of belly pain. Last drink was at 4PM yesterday; currently not feeling shaky. She said that she continues to drink because of the death of her son. REVIEW OF SYSTEMS: Pertinent for some chills. Some loose stools. Nausea, some non-bloody vomiting. Dark stool but not tarry. Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Alcohol abuse (more than 1 gallon vodka daily) - COPD - Hepatitis C (reportedly presently discussing potential treatment options) - Hypertension - S/p Cesarean section x 3 - Cirrhosis (diagnosed radiologically) Social History: ___ Family History: Her father is alive and is an alcoholic and her mother is alive and has AFIB. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VITALS: 98.6, 124/64, 92, 16, 99%RA GEN: No apparent distress; disheveled HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular, no murmurs/gallops/rubs PULM: Bilateral wheezes throughout GI: +distention; no guarding/rebound; normal bowel sounds; no tenderness to palpation in any quadrant; left lower abdomen has three ~1cmx1cm scabs that are evenly spaced and surrounded with a small amount of erythema but no pus/discharge and no fluctuance EXT: 2+ distal pulses; 2+ pitting edema to the knees bilaterally NEURO: Alert and oriented to person, place and situation; CN II-XII intact, ___ motor function globally; + tremor DISCHARGE PHYSICAL EXAMINATION: GEN: Encephalopathic; confused and not oriented to time/place, calm HEENT: PERRL, MMM CV: RRR, no M/R/G PULM: crackles at bases GI: NABS, tenderness to palpation diffusely, no rebound/guarding, no ascites EXT: left thigh hematoma extending from groin to knee (improving), 3+ pitting ___ edema NEURO: Confused, + asterixis Pertinent Results: ADMISSION LABS: ___ 12:55AM BLOOD WBC-5.7# RBC-3.20* Hgb-10.1* Hct-31.9* MCV-100* MCH-31.7 MCHC-31.8 RDW-16.5* Plt ___ ___ 12:55AM BLOOD Neuts-69.3 ___ Monos-5.6 Eos-0.6 Baso-0.2 ___ 12:55AM BLOOD ___ PTT-30.0 ___ ___ 12:55AM BLOOD Plt ___ ___ 12:55AM BLOOD Glucose-104* UreaN-9 Creat-0.5 Na-138 K-3.1* Cl-97 HCO3-26 AnGap-18 ___ 12:55AM BLOOD ALT-73* AST-367* AlkPhos-658* TotBili-7.6* DirBili-5.5* IndBili-2.1 ___ 12:55AM BLOOD Lipase-96* ___ 12:55AM BLOOD cTropnT-<0.01 ___ 12:55AM BLOOD Albumin-3.1* Calcium-8.1* Phos-1.4* Mg-1.8 ___ 12:55AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:00AM BLOOD ___ Temp-37.4 pO2-143* pCO2-34* pH-7.54* calTCO2-30 Base XS-7 Comment-GREEN TOP ___ 01:00AM BLOOD Lactate-3.1* ___ 04:35AM BLOOD GGT-2421* ___ 12:55AM BLOOD Lipase-96* ___ 07:55AM BLOOD Lipase-200* HEPATITIS WORK UP: ___ 04:35AM BLOOD GGT-2421* ___ 09:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE IgM HBc-NEGATIVE ___ 09:45AM BLOOD HCV Ab-POSITIVE* DISCHARGE LABS: ___ 06:50AM BLOOD WBC-10.2 RBC-3.36* Hgb-10.2* Hct-33.0* MCV-98 MCH-30.3 MCHC-30.9* RDW-17.7* Plt ___ ___ 07:12AM BLOOD ___ ___ 06:50AM BLOOD UreaN-86* Creat-6.3* Na-127* K-4.8 Cl-94* ___ 06:50AM BLOOD ALT-45* AST-192* TotBili-31.1* ___ 07:15AM BLOOD Calcium-8.3* Phos-6.8* Mg-2.6 IMAGING STUDIES: RUQ US ___ - Hepatopetal flow is seen within the left portal vein, however flow within the main portal vein is not definitely demonstrated due to limiations by poor penetration of liver. If there is further concern for portal venous thrombosis, this could be better assessed with contrast-enhanced CT. CT ABD/PELVIS ___ - No evidence of intra- or extra-hepatic biliary ductal dilatation or portal vein thrombosis. No CT evidence of acute pancreatitis. Findings in the liver most suggestive of cirrhosis with hepatic steatosis. Large left flank herniation containing loop of the colon without evidence of strangulation. CXR ___ - No acute chest abnormality. RENAL U/S ___ - No hydronephrosis. Small nonobstructing stone in the right kidney and tiny peripheral crystal noted in the left kidney. LENIs ___ - Adequate compression of the deep veins within the left lower extremity demonstrating no acute thrombus. Evaluation of the right leg and color Doppler imaging could not be completed as the patient declined further examination. RUQUS ___ - Technically very limited exam, limiting evaluation of the abdominal structures. No large hepatic mass is identified. Main portal vein is patent with hepatopetal flow. CXR ___ - As compared to the previous radiograph, the signs suggestive of pulmonary edema have decreased. There is no evidence of focal parenchymal opacities suggesting pneumonia. Borderline size of the cardiac silhouette. No pleural effusions. No other lung parenchymal abnormalities. CT ABD/PELVIS/HIP ___ - 1. New left adductor longus hematoma. No active extravasation detected. 2. Unchanged left lateral hernia involving the splenic flexure. Trace neighboring fluid is detected, tracking into the pelvis. There are no advanced signs of bowel incarceration or strangulation. Correlate with any focal tenderness. REPEAT CT ABD/PELVIS/HIP ___ - Left adductor brevis hematoma appears increased in size since the most recent prior examination allowing for differences in technique with fluid-fluid level noted measuring 9.2 x 11.2 x 8.4 cm. CT ABD/PELVIS ___ non-con IMPRESSION: 1. Small-bowel obstruction without a definite transition point. Evaluation of the mucosa is limited by the lack of IV contrast, however, there is no apparent bowel wall edema supporting a mechanical etiology. Although, given the mesenteric edema, ischemia should be considered but is deemed to be less likely and correlation with lactate levels is recommended. 2. Cirrhosis with sequela of portal hypertension marked by varices and splenomegaly. 3. Splenic flexure hernia containing large bowel without evidence of obstruction. 4. No tapable ascites. Brief Hospital Course: ___ year old homeless female with a h/o nephrolithiasis, cirrhosis, alcohol abuse, COPD, and Hepatitis C who presented with acute alcoholic hepatitis. Hospital course was complicated by the development of hepatic encephalopathy, hepatic coagulopathy, nephrolithiasis, infection of unknown origin, spontaneous left adductor brevis hematoma formation, and rapidly progressive renal failure. ACTIVE ISSUES: #Alcoholic Hepatitis: Initial imaging with RUQU S and CT abd showed evidence of cirrhosis but no PVT, gallstones, pancreatitis or dilated biliary tree. Infectious hepatitis labs showed evidence of prior HBV infection without development of immunity, and current HCV infection with a viral load of 4,000. The patients clinical status gradually deteriorated throughout her hospital stay with total bilirubin rising to 31, with MELD >40. She was initially treated with adequate nutrition and pentoxifylline (given acute renal failure on presentation), but soon was transitioned to prednisone once renal failure improved with albumin. She was treated with prednisone for a total of six days, at which time it was discontinued due to a rising leukocytosis, fever and presumed infection. She was treated with broad spectrum antibiotics, but source of the infection could not be identified. She developed a spontaneous left thigh hematoma that was initially a potential source of superinfection, however a superficial collection in the thigh was drained without bacterial growth. She was treated empirically for a skin/soft tissue infection for nearly 10 days of ceftriaxone. Unfortunately her liver failure continued to progress. She concurrently developed rapidly progressive renal failure starting the week of ___. Renal failure was either secondary to contrast induced nephropathy from a CT scan of her thigh, or secondary to development of hepatorenal syndrome. She was followed by the hepatology and nephrology consulting teams. She was treated with octreotide, midodrine and albumin, but unfortunately neither her liver or kidneys responded. Long discussions took place between the medicine team, hepatologists, nephrologists and the patient and her family. Palliative care was consulted. Ultimately given her poor prognosis, the patient voiced her desire to switch care to comfort care and not pursue dialysis. Her pain was treated with pain medications and she was continued on lactulose to prevent encephalopathy. She changed her code status to DNR/DNI during these discussions, in keeping with her expressed wishes and her family's views. She became encephalopathic on ___. She has been continued on lactulose and rifaximin to try to contain her encephalopathy so that she can spend time with her family when transitioned to hospice. She is DNR/DNI and is transitioning to hospice care. Medications on Admission: 1. Metoprolol Tartrate 25 mg PO BID 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Gabapentin 600 mg PO TID 4. Ipratropium Bromide MDI 2 PUFF IH QID 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath/wheezing 6. Furosemide 20 mg PO DAILY 7. Nicotine Patch 14 mg TD DAILY 8. Multivitamins 1 TAB PO DAILY 9. Thiamine 100 mg PO DAILY Discharge Medications: 1. Lactulose 30 mL PO TID Please titrate to ___ BM per day 2. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain please hold for sedation RX hydromorphone 2 mg ___ tablet(s) by mouth q4H PRN pain Disp #60 Tablet Refills:*0 3. Rifaximin 550 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: alcoholic hepatitis acute renal failure infection NOS spontaneous hematoma formation in the left hip adductor muscle nephrolithiasis SECONDARY DIAGNOSES: EtOH and HCV Cirrhosis COPD Rat Bites Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. You came to the hosptial with fatigue, shortness of breath, abddominal pain, nausea/vomiting and fevers chills. You were found to have alcoholic hepatitis as a result of your alcohol use. Unfortunately despite our best efforts with medications, your liver continued to fail. Your kidneys also started to fail throughout your hospital stay despite treatment. This was likely a result of your severe liver failure. You were seen by the liver and kidney specialists throughout your stay. It was ultimately decided after talking with you that your care should be transitioned to comfort and you were discharged to a ___ facility closer to your family. Followup Instructions: ___
19828913-DS-19	19,828,913	29,177,730	DS	19	2141-04-10 00:00:00	2141-04-15 10:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ Laparoscopic Cholecystectomy History of Present Illness: Mr. ___ is a ___ with a 2 day history of abdominal pain associated with 1 day history of nausea/vomiting. He presented to ___, where he was found to have an elevated WBC and an abdominal US was obtained which revealed enlargement of the CBD at 9mm, with distal tapering, and a possible filling defect seen present near the cystic duct. General surgery was consulted and requested a CT scan, which revealed acute cholecystitis with pericholecystic fluid, wall thickening, no pericolonic inflammatory stranding, no bowel obstruction, and a normal-appearing appendix. The CT imaging was also concerning for a possible filling defect in the aorta, which was concerning for the possibility of intimal flap and/or thrombus. He denies ever having similar pain in the past. Of note, the patient does report some pain with ambulation in his left foot that began 6 months ago. Patient was transferred to ___ for further evaluation by Vascular and General Surgery. Past Medical History: PAST MEDICAL HISTORY: - Denies any medical problems, mentions maybe HTN PAST SURGICAL HISTORY: - Left forearm fracture requiring open repair and ? plate fixation - Right prosthetic elbow - Left knee repair including metallic hardware (all in ___ Social History: ___ Family History: Mother: COPD Physical ___: Admission PHYSICAL EXAM: VITAL SIGNS: 98.3 89 126/86 17 97% RA GENERAL: AAOx3 NAD HEENT: NCAT, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: R/R/R, S1/S2 PULMONARY: unlabored breathing, CTA ___ GASTROINTESTINAL: soft, nondistended, mildly tender diffusely worse in his RUQ. No guarding, rebound, or peritoneal signs. EXT/MS/SKIN: No C/C/E; Feet warm. palpable ___ on R, L foot with some very mild chronic skin changes and faint ___ and AT NEUROLOGICAL: Reflexes, strength, and sensation grossly intact Discharge Physical Exam: VS: 97.9, 146/77, 85, 18, 94 Ra Gen: A&O x3, sitting up in chair Pulm: LS ctab CV: HRR Abd; soft, NT/ND. Lap sites CDI with dermabond Ext: No edema Pertinent Results: ___ 05:00AM BLOOD WBC-14.2* RBC-4.59* Hgb-13.6* Hct-41.8 MCV-91 MCH-29.6 MCHC-32.5 RDW-13.2 RDWSD-44.3 Plt ___ ___ 07:09AM BLOOD WBC-16.5* RBC-4.36* Hgb-13.5* Hct-38.4* MCV-88 MCH-31.0 MCHC-35.2 RDW-13.3 RDWSD-43.2 Plt ___ ___ 04:44AM BLOOD WBC-17.0* RBC-5.01 Hgb-15.3 Hct-46.4 MCV-93 MCH-30.5 MCHC-33.0 RDW-14.3 RDWSD-47.6* Plt ___ ___ 05:00AM BLOOD Glucose-96 UreaN-12 Creat-0.6 Na-138 K-4.2 Cl-99 HCO3-25 AnGap-14 ___ 07:09AM BLOOD Glucose-156* UreaN-7 Creat-0.6 Na-140 K-4.0 Cl-102 HCO3-26 AnGap-12 ___ 09:45AM BLOOD Glucose-144* UreaN-6 Creat-0.6 Na-136 K-4.4 Cl-100 HCO3-22 AnGap-14 ___ 05:00AM BLOOD ALT-108* AST-95* AlkPhos-72 TotBili-0.7 ___ 07:09AM BLOOD ALT-79* AST-66* LD(LDH)-187 AlkPhos-66 TotBili-1.4 ___ 09:45AM BLOOD ALT-58* AST-33 AlkPhos-72 TotBili-1.1 ___ 05:00AM BLOOD Calcium-9.0 Phos-2.1* Mg-2.2 Imaging: Chest CT: 1. No evidence of aortic dissection, aneurysm or intramural hematoma. 2. Focal linear intraluminal thrombus within the descending thoracic aorta. 3. 4 cm left lobe thyroid nodule. Further evaluation with thyroid ultrasound is recommended per ACR criteria as noted below. Thyroid US: Bilateral thyroid cysts measuring up to 3.6 cm without sonographically worrisome features. Follow-up thyroid ultrasound in ___ months is recommended to assess for stability and need for sampling. PATHOLOGIC DIAGNOSIS: Gallbladder, cholecystectomy: Severe, focally transmural acute cholecystitis with necrosis and fibrinopurulent serositis. Brief Hospital Course: ___ is a ___ yo M who presented to outside hospital with abdominal pain, nausea/vomiting found to have acute cholecystitis on ultra sound. A CT scan was done and again demonstrated acute cholecystitis with incidental finding of a possible filling defect in the aorta concerning for the possibility of intimal flap and/or thrombus. Therefore he was transferred to ___. Vascular surgery was consulted and recommended repeat CTA which showed no aortic dissection but a focal linear intraluminal thrombus within the descending thoracic aorta. Another incidental finding on CT was a 4 cm left lobe thyroid nodule. Thyroid ultrasound was done which showed the nodule to be a cyst. Recommended follow-up imaging in ___ months. Vascular surgery post operative recommendations were to start xeralto once cleared from surgical perspective, start statin therapy, and outpatient vascular follow up with Dr. ___. The patient underwent laparoscopic cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating sips, on IV fluids, and oral analgesia with IV breakthrough for pain control. The patient was hemodynamically stable. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Upon discharge he was started on xarelto and a statin, and would follow-up with Vascular. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H RX acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #20 Capsule Refills:0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 5. Rivaroxaban 15 mg PO BID RX rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 6. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Acute Cholecystitis Incidental Findings: [] Thrombus of thoracic aorta [] Thyroid nodule Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the Acute Care Surgery Service on ___ with abdominal pain and found to have an infection in your gallbladder. You were taken to the operating room and had it removed laparoscopically. You are now doing better, tolerating a regular diet, and ready to be discharged to home to continue your recovery. You had two incidental findings on your CT scan: 1.) A blood clot in your aorta. The Vascular surgery team saw you for this and recommend taking a medication to thin your blood (anticoagulation). This medication, Xarelto, is taken twice a day. You have also been started on Atorvastatin, a medication to lower cholesterol. Please follow-up in the ___ clinic with Dr ___ at the appointment listed below. 2.) A thyroid nodule. The Endocrine surgery team saw you for this and an ultrasound was obtained. They recommend following up as an outpatient with Dr. ___ further monitoring. Please note the following discharge instructions: Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
19829765-DS-3	19,829,765	29,991,697	DS	3	2137-05-05 00:00:00	2137-06-01 21:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: epigastric pain Major Surgical or Invasive Procedure: Laparoscopic Cholecystectomy History of Present Illness: ___ h/o ___ transferred from ___ found to have choledocholithiasis. She initially presented with 2 hours acute onset epigastric pain radiating around to her back like a band associated with nonbloody vomiting. The pain is similar to her previous episode of gallstone disease ___ years ago. She took TUMS and ibuprofen with some relief. Pain is not related to food, but deep breathing makes the pain worse. Pain was initially ___ now improved to ___. ROS: -sweats overnight. Denies jaundice/icterus or GERD/indigestion. -as above otherwise 10point ROS negative Past Medical History: -thyroid cancer 20+ years ago s/p resection and subsequent hypothyroidism. Post surgical PE on anticoagulation for 6 months. Past Medical History: -History of pulmonary embolism and DVT treated with 6 months of Coumadin -Thyroid cancer Past Surgical History: total thyroidectomy ___ years ago Lap CCY ___ (Dr. ___ Social History: ___ Family History: -Mother: colon cancer age ___, alive -Father: colon cancer age ___, deceased Physical Exam: -Vitals: Afebrile and vital signs stable (reviewed in OMR) -General Appearance: pleasant, comfortable, no acute distress -Eyes: PERLL, EOMI, no conjuctival injection, anicteric -ENT: no sinus tenderness, moist mucus membranes, atraumatic, normocephalic -Respiratory: clear bl, no wheeze -Cardiovascular: RRR, no murmur -Gastrointestinal: soft, nontender, nondistended, bowel sounds present -GU: no foley, no CVA tenderness -Musculoskeletal: no cyanosis, clubbing or edema -Skin: warm, no rashes/no jaundice/no skin ulcerations noted -Neurological: AAOx3, no focal neurological deficits, CN ___ grossly intact -Psychiatric: pleasant, appropriate affect Pertinent Results: ___ 12:10AM BLOOD WBC-8.3 RBC-3.74* Hgb-12.3 Hct-36.0 MCV-96 MCH-32.9* MCHC-34.2 RDW-12.8 RDWSD-45.2 Plt ___ ___ 12:10AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-143 K-4.2 Cl-107 HCO3-23 AnGap-13 ___ 12:10AM BLOOD ALT-119* AST-101* AlkPhos-81 TotBili-0.6 ___ 12:10AM BLOOD Lipase-971* Brief Hospital Course: ___ was admitted on ___ under the acute care surgery service for management of cholelithiasis, gallstone pancreatitis. She was taken to the operating room and underwent a laparoscopic cholecystectomy. Please see operative report for details of this procedure. She tolerated the procedure well and was extubated upon completion. She was subsequently taken to the PACU for recovery. She was transferred to the surgical floor hemodynamically stable. Her vital signs were routinely monitored and she remained afebrile and hemodynamically stable. She was initially given IV fluids postoperatively, which were discontinued when she was tolerating PO's. Her diet was advanced to regular, which she tolerated without abdominal pain, nausea, or vomiting. She was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently. Her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On ___, she was discharged home with scheduled follow up in ___ clinic on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 137 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild do not exceed 4 grams/24 hours RX acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID:PRN constipation RX docusate sodium [Stool Softener] 100 mg 1 tablet(s) by mouth twice a day Disp #15 Tablet Refills:0 3. Senna 17.2 mg PO DAILY:PRN constipation 4. Levothyroxine Sodium 137 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Choledocolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted for a gallstone that was blocking your bile ducts. Although the stone passed on it's own surgery recommended removing your gallbladder to prevent this from occurring again. You underwent laparoscopic removal of your gallbladder and tolerated the procedure well. You are now doing better, tolerating a regular diet, pain is controlled, and you are ready to be discharged to home with the following discharge instructions: ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
19829815-DS-13	19,829,815	20,860,006	DS	13	2204-09-19 00:00:00	2204-09-19 15:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Worsening anemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with systolic CHF, CAD, HTN, HL, DM on insulin, CKD stage III with intermittent hyperkalemia, cirrhosis with esophageal varices, hypovitaminosis D, anemia of chronic disease with coexistent iron deficiency previously on iron infusions, gastric polyps with slow bleeding, who presents with worsening anemia, referred from his ___ for blood transfusion. The patient reports that ___ has been essentially in his usual state of health for the past several weeks. ___ has noticed dizziness and mild lightheadedness on standing and with ambulation, but that is his only complaint. On reviewing records it appears ___ mentioned this on ___ at his cardiology appointment at that time ___ was not orthostatic and ___ was encouraged to take time with position changes. His furosemide dose was also decreased to 40 mg daily from 60. ___ has been having some difficulty with his blood sugars of late; they have been high. Today ___ presented to the ___ clinic for further evaluation of his hyperglycemia and adjustment of his insulin. Routine laboratory studies at ___ showed worsening anemia with a hemoglobin of 6.1 hematocrit of 20. With the complaints of dizziness, the physician at ___ advised him to go to the emergency room for blood transfusion. In the emergency room ___ had entirely stable vital signs. ___ had labs that were notable for stable BNP with mild hyperkalemia. Chest x-ray was unremarkable. EKG was reportedly unchanged. ___ was transfused 1 unit of blood and the decision was made to request admission for observation and a second unit of blood given his history of mild systolic CHF. ___ currently reports his dizziness and lightheadedness with standing is improved after the 1 unit blood transfusion. REVIEW OF SYSTEMS A full 10 point review of systems was performed and is otherwise negative except as noted above. Past Medical History: CHRONIC KIDNEY DISEASE CORONARY ARTERY DISEASE DIABETES MELLITUS HYPERLIPIDEMIA HYPERTENSION EOSINOPHILIA ANEMIA OF CHRONIC DISEASE ABDOMINAL PAIN CONSTIPATION CIRRHOSIS Social History: ___ Family History: Negative for DM, HTN, cancer or heart disease. Physical Exam: Vitals: ___ 1838 Temp: 98.2 PO BP: 168/66 HR: 62 RR: 18 O2 sat: 100% O2 delivery: RA FSBG: 289 Gen: NAD, lying in bed, wife present Eyes: ___, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA ___ without adventitious sounds. GI: Soft, NT, mild gaseous distention, BS+. No HSM. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Able to get himself up from a recumbent position with minimal assistance. Psych: Full range of affect. Thought linear. Speaks a combination of ___ and ___. GU: No foley Pertinent Results: ___ 07:16AM BLOOD WBC-8.7 RBC-3.14* Hgb-8.3* Hct-26.0* MCV-83 MCH-26.4 MCHC-31.9* RDW-14.0 RDWSD-42.3 Plt ___ ___ 07:16AM BLOOD ___ ___ 07:16AM BLOOD Glucose-145* UreaN-39* Creat-1.9* Na-140 K-5.1 Cl-101 HCO3-22 AnGap-17 ___ 07:16AM BLOOD ALT-10 AST-17 LD(LDH)-176 AlkPhos-103 TotBili-1.3 ___ 07:16AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.2 ___ 11:45AM BLOOD Iron-30* ___ 11:45AM BLOOD calTI___ Ferritn-22* TRF-357 ___ 07:16AM BLOOD TSH-6.5* CXR: FINDINGS: Lungs are fully expanded and clear. No pleural abnormalities. Heart size is top-normal. Cardiomediastinal and hilar silhouettes are normal. IMPRESSION: No evidence of an acute cardiopulmonary abnormality. Brief Hospital Course: This is a ___ with systolic CHF, CAD, HTN, HL, DM on insulin, CKD stage III with intermittent hyperkalemia, cirrhosis with esophageal varices, hypovitaminosis D, anemia of chronic disease with coexistent iron deficiency previously on iron infusions and epo, gastric polyps with slow bleeding, who presents with worsening anemia, referred from his ___ for blood transfusion. # Worsening of chronic mixed anemia (ACD and ___ # Lightheadedness on standing, consisistent with # Symptomatic anemia: The differential diagnosis for his anemia included acute blood loss in the setting of GI bleeding (from gastric polyps or potentially esophageal varices), slow GI blood loss from the same sources, progression of underlying anemia in the setting of not receiving IV iron or Epo. Hemolysis, sequestration are unlikely given his history. ___ responded appropriately to 2 units and felt well with no symptoms whatsoever. His labs were suggestive of ongoing iron deficiency anemia. ___ had no evidence of acute GI bleeding. His cirrhosis was compensated. ___ was due for screening EGD which was considered inpatient. I reviewed this with ___, his wife, and his primary gastroenterologist. We all agreed that the patient may have this as an outpatient. - PCP follow up for CBC check within 2 weeks - Patient will likely require initiation again of iron transfusions. - Outpatient EGD with his gastroenterologist # Cirrhosis with history of varices: It appeared that ___ saw Dr. ___ Dr. ___ in clinic relatively recently. ___ carries a diagnosis of presumed and ASH cirrhosis - Continued home medications including Lactulose HS, Propranolol ___ - ___ is compensated at this time # HTN # HL # CAD # Chronic systolic CHF: Appears euvolemic. -Continued home medications including Losartan, ASA, Simvastatin, Lasix # CKD: Stable - Monitor Cr and avoid nephrotoxins as able # Hyperkalemia: ___ has received Kayexalate in the past though it is not clear whether ___ takes this on a regular basis. His potassium on admission was slightly higher at 5.6 then some of the other values we have in our system. Normalized on discharge # DM2 on insulin: ___ has had recent difficulty with hypoglycemia and saw a provider at ___ for this on the day of his presentation. At that visit they increased his insulin dosing slightly and provided him with a new sliding scale, however his sliding scale document in the ___ records is somewhat confusing regarding his lunchtime sliding scale. -Continue insulin while here. We will place him on a slightly lower dose of long-acting insulin along with a more standard hospital grade sliding scale and some mealtime bolus insulin. In looking at his outpatient records this appears to be a rough approximation of his usual regimen. # Chronic constipation: Stable. - Continue home bowel regimen Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 40 mg PO QPM 2. Losartan Potassium 75 mg PO DAILY 3. Vitamin D ___ UNIT PO DAILY 4. Aspirin 81 mg PO DAILY 5. Furosemide 60 mg PO DAILY 6. Propranolol ___ 60 mg PO DAILY 7. Lactulose 30 mL PO QHS 8. Senna 17.2 mg PO DAILY 9. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN Hyperkalemia 10. Toujeo 45 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Toujeo 45 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. Aspirin 81 mg PO DAILY 3. Furosemide 60 mg PO DAILY 4. Lactulose 30 mL PO QHS 5. Losartan Potassium 75 mg PO DAILY 6. Propranolol ___ 60 mg PO DAILY 7. Senna 17.2 mg PO DAILY 8. Simvastatin 40 mg PO QPM 9. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN Hyperkalemia 10. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Chronic multifactorial anemia: Blood loss Iron deficiency Chronic disease Cirrhosis CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after found to have an worsened anemia. This responded well to 2 blood transfusions. We did not see any evidence of bleeding. After speaking with your gastroenterologist Dr ___ recommends that you have a routine follow up EGD which ___ will arrange. Please also have your blood counts checked on next follow up with your PCP. We recommend your resume your iron infusions Followup Instructions: ___
19829815-DS-14	19,829,815	24,127,067	DS	14	2205-01-27 00:00:00	2205-01-28 15:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue, anemia Major Surgical or Invasive Procedure: Upper Endoscopy ___ History of Present Illness: Mr. ___ is a ___ with systolic CHF, CAD, HTN, HL, DM on insulin, CKD stage III with intermittent hyperkalemia, cirrhosis with esophageal varices, anemia of chronic disease with coexistent iron deficiency previously on iron infusions, gastric polyps with slow bleeding, who presents with worsening anemia. Recent admission with similar presentation on ___. He received iron infusions as an outpatient ___ and ___. EGD was done in ___ for concern for chronic slow GI blood loss showed 2 cords of grade II varices in the distal esophagus w/o bleeding and multiple pedunculated non-bleeding polyps in the stomach rangin in size from 8-25mm, which were biopsied. Otherwise normal mucosa. Pathology from which showed ulcerated inflammatory polyp, negative for h. pylori. In the ED, initial VS were: 97.8 67 135/37 14 100% RA Exam notable for: Rectal guaiac pos brown stool. ECG: NSR, IVCD with leftward axis, lateral and inferior ST and T-wave changes are non-specific but could represent ischemia. Possible prior inferior MI. Poor R-wave progression, possible prior anterior MI. Unchanged from prior. Labs showed: hgb 6.9 -> 6.2. Lactate 1.9. Cr 2.3 (baseline). K 5.5. Ferritin 15. INR 1.2 Imaging showed: RUQUS 1. Cholelithiasis without gallbladder wall thickening. 2. Cirrhotic morphology liver and mild ascites. No focal liver lesion. Consults: Liver - consulted but no rec's Patient received: Ordered for 2 U PRBC's Transfer VS were: 74 138/70 16 99% RA On arrival to the floor, patient reports lightheadedness on standing but no other complaints. He was sent in because screening lab work showed low hgb, he had no symptoms, blood in stool or melena. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: CKD CAD T2DM HLD HTN Anemia, ___ and ICD Cirrhosis with h/o varices Gastric polyps Social History: ___ Family History: Negative for DM, HTN, cancer or heart disease Physical Exam: ADMISSION PHYSICAL EXAM: VS:98.0PO 176 / 72 65 16 100 RA GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ___ 0818 Temp: 95.9 AdultAxillary BP: 157/80 HR: 69 RR: 18 O2 sat: 98% O2 delivery: RA FSBG: 66 GENERAL: elderly man, NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple CV: RRR, no murmurs appreciated PULM: clear to auscultation bilaterally, no wheezes or crackles GI: soft, nontender, nondistended, no hepatosplenomegaly EXTREMITIES: no ___ edema, no asterixis PULSES: 2+ radial pulses bilaterally NEURO: Alert, no focal deficits DERM: warm and well perfused, no rashes Pertinent Results: ___ 02:55PM BLOOD Hgb-6.9* Hct-22.6* ___ 02:55PM BLOOD WBC-7.1 RBC-2.60* Hgb-6.9* Hct-22.8* MCV-88 MCH-26.5 MCHC-30.3* RDW-14.8 RDWSD-47.7* Plt ___ ___ 09:45PM BLOOD Neuts-67.4 Lymphs-9.1* Monos-12.7 Eos-9.9* Baso-0.3 NRBC-0.3* Im ___ AbsNeut-4.23 AbsLymp-0.57* AbsMono-0.80 AbsEos-0.62* AbsBaso-0.02 ___ 02:55PM BLOOD ___ ___ 09:45PM BLOOD ___ PTT-26.3 ___ ___ 09:45PM BLOOD Ret Aut-2.5* Abs Ret-0.05 ___ 02:55PM BLOOD UreaN-37* Creat-2.3* Na-141 K-5.5* Cl-103 HCO3-23 AnGap-15 ___ 02:55PM BLOOD ALT-8 AST-16 AlkPhos-109 TotBili-0.4 DirBili-<0.2 IndBili-0.4 ___ 02:55PM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.5 Iron-22* ___ 02:55PM BLOOD calTIBC-406 Ferritn-15* TRF-312 ___ 02:55PM BLOOD PTH-99* ___ 02:55PM BLOOD AFP-1.4 ___ 09:49PM BLOOD Lactate-1.9 ___ 11:11PM URINE Color-Straw Appear-Clear Sp ___ ___ 11:11PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 11:11PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 11:11PM URINE Mucous-RARE* ___ 02:55PM URINE Hours-RANDOM Creat-96 Albumin-12.8 Alb/Cre-133* DISCHARGE LABS: ___ 08:45AM BLOOD WBC-9.8 RBC-3.82* Hgb-10.5* Hct-32.8* MCV-86 MCH-27.5 MCHC-32.0 RDW-14.8 RDWSD-45.4 Plt ___ ___ 08:45AM BLOOD ___ PTT-29.6 ___ ___ 08:45AM BLOOD Glucose-84 UreaN-30* Creat-1.6* Na-138 K-4.6 Cl-104 HCO3-22 AnGap-12 ___ 08:45AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.3 Mg-2.1 ___ 07:37AM BLOOD calTIBC-386 Ferritn-25* TRF-297 ___ 08:45AM BLOOD ALT-8 AST-23 LD(LDH)-205 AlkPhos-107 TotBili-0.7 ___ 04:17PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:17PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 04:17PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 04:17PM URINE Mucous-RARE* MICRO: ___ 11:11 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 2:35 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 4:10 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 4:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. IMAGING REPORTS: ___ LIVER OR GALLBLADDER US IMPRESSION: 1. Cholelithiasis without gallbladder wall thickening or findings of acute cholecystitis. 2. Cirrhotic morphology liver and small amount of ascites as on prior. No focal liver lesion. ___ EGD IMPRESSIONS: - Varices in the distal esophagus (Ligation). - Polyps (3 mm to 20 mm) in the antrum. - Normal mucosa in the whole duodenum. RECOMMENDATIONS: - Omeprazole 20 mg twice daily, Carafate 2 gm twice daily for two weeks. Soft diet for 24 hours and then advance diet as tolerated to a regular diet. - EGD in 1 month for repeat banding. Brief Hospital Course: BRIEF SUMMARY: Mr. ___ is a ___ with systolic CHF, CAD, HTN, HL, DM on insulin, CKD stage III with intermittent hyperkalemia, cirrhosis with esophageal varices, anemia of chronic disease with coexistent iron deficiency previously on iron infusions, gastric polyps with slow bleeding, who presents with worsening anemia. ACTIVE ISSUES: # Esophageal varices Patient presented with Hgb 6.9. He received 2 units of pRBCs with an appropriate response to Hgb 10.5. EGD revealed 3 cords of grade II varices in the esophagus and were that were banded. Several friable pedunculated inflammatory polyps (3 mm - 20 mm) were noted in the antrum. Antibiotic ppx initially ceftriaxone ___ was switched to Ciprofloxacin on ___. Patient was started on omeprazole and Carafate. He was restarted on home propranolol. Discharge Hgb 10.5. # Acute on chronic anemia Patient presented with Hgb 6.9 and received 2 units of pRBCs with increase to Hgb 10.5. Esophageal varices were banded. Patient received an iron infusion for low ferritin levels. Discharge Hgb 10.5. # NASH cirrhosis Decompensated by portal hypertension leading to variceal bleed. Patient was euvolemic and did not have asterixis or ascites on exam. Diuretics and propanolol were initially held while he continued on lactulose. On day of discharge, home furosemide was restarted at reduced dose of 20 mg daily. # DM2 on insulin Patient initially continued on home insulin regimen. He had recurrent episodes of AM hypoglycemia to 50-60s despite dose reduction to 80%, hence insulin regimen was further adjusted. He will be discharged on insulin dose of 20 units insulin degludec [Tresiba] + SSI with close outpatient follow up. Of note, his most recent HgbA1c as outpatient was 5.91% CHRONIC ISSUES: # CKD - Patient's Cr remained at baseline. He was given an iron infusion in the setting of low ferritin levels and anemia likely secondary to renal disease. # H/o CAD # CHF, ICM - held losartan and resumed when clinically stable # HLD: Cont. statin # HTN: Restarted propranolol once clinically stable TRANSITIONAL ISSUES: [ ] Needs to recheck CBC and chemistries in 1 week. Discharge Hgb 10.5. [ ] End date for ciprofloxacin for SBP prophylaxis in setting of GIB is ___. [ ] Needs to f/u on insulin regimen. Discharged with reduced dose of 20 units insulin degludec [___]. This was communicated to his PCP. [ ] Needs to f/u with hepatology and have repeat endoscopy in ___ weeks. [ ] Discharged on reduced dose of Lasix to 20 mg PO daily. [ ] Discharge weight is 69 kg. No evidence of volume overload. [ ] Needs to continue Carafate 2g BID until ___. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Furosemide 60 mg PO DAILY 3. Lactulose 30 mL PO QHS 4. Losartan Potassium 75 mg PO DAILY 5. Propranolol LA 60 mg PO DAILY 6. Senna 17.2 mg PO DAILY 7. Simvastatin 40 mg PO QPM 8. Vitamin D ___ UNIT PO DAILY 9. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN Hyperkalemia Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO DAILY Duration: 4 Days Take one tablet daily starting ___. RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #4 Tablet Refills:0 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Omeprazole 20 mg PO BID RX omeprazole 20 mg 1 capsule(s) by mouth twice daily Disp #60 Capsule Refills:0 4. Sucralfate 2 gm PO BID RX sucralfate [Carafate] 1 gram 2 tablet(s) by mouth twice daily Disp #48 Tablet Refills:0 5. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Humalog 8 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Other 20 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 7. Aspirin 81 mg PO DAILY 8. Lactulose 30 mL PO QHS 9. Losartan Potassium 75 mg PO DAILY 10. Propranolol LA 60 mg PO DAILY 11. Senna 17.2 mg PO DAILY 12. Simvastatin 40 mg PO QPM 13. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN Hyperkalemia 14. Vitamin D ___ UNIT PO DAILY 15.Outpatient Lab Work Please draw on ___ CBC and Chem 10 including LFTs. Fax to Dr. ___ ___, and Dr. ___ ___. ___ cirrhosis K75.81 GI bleed K92.2 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Esophageal varices Acute blood loss anemia Type 2 diabetes on insulin Secondary diagnosis: ___ cirrhosis Chronic kidney disease Heart failure with preserved ejection fraction CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___! WHY WERE YOU ADMITTED? -You were admitted for very low blood counts. WHAT HAPPENED IN THE HOSPITAL? - You received a blood transfusion. - You got an Upper Endoscopy which showed varices (vessels that can bleed) in your esophagus. The varices were banded to stop and prevent bleeding. - You were given medications to prevent bleeding and infection. - You were given iron for low iron levels. - You were also found to have low blood sugar levels, so your insulin was adjusted WHAT SHOULD YOU DO AT HOME? - Take your medications as prescribed - Follow up with your liver doctor ___ need a repeat upper endoscopy to make sure there are no further bleeding blood vessels in one month). - Follow up with your primary care doctor to make sure that your blood sugars are controlled. Please note that we DECREASED your insulin dose while you were here because you were having low blood sugars in the AM. Thank you for allowing us be involved in your care, we wish you all the best! Your ___ Team Followup Instructions: ___
19829815-DS-15	19,829,815	26,965,273	DS	15	2205-12-02 00:00:00	2205-12-02 20:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M with history of CKD, CHF (LVEF = 47 %), anemia of chronic disease, CAD, DM, HLD, HTN, cirrhosis who presents with hypoglycemia. History obtained from patient and family at bedside. He was in his USOH this morning, ate breakfast and lunch. He was found after lunch by his wife to be confused, altered, and nearly unresponsive. EMS was called and BS was 33. He was given 20 gm D10 with improvement in BS to 92 with some improvement in MS. ___ on arrival to ___ ED 76. Per family, he seems near baseline but still has some dysarthria. He denies recent fevers, chills, cough, SOB, chest pain, abdominal pain, diarrhea, dysuria. He did have a fall last week with residual heel pain, which was described as mechanical when getting out of bed. He has a scab on his L knee after this fall, which has healed well without signs of infection. - In the ED, initial vitals were: 62 BP 166/67 RR 18 O2 99% RA - Exam was notable for: VSS, glucose 76 Gen: Alert and awake, dysarthric HEENT: Mucous membranes dry CV: Regular Lungs: CTAB Abd: +BS, soft, NT, ND Ext: Heeled scab on L knee. Pain on palpation of L heel, full ROM - Labs were notable for: 7.2 7.7>----<134 24.2 143 108 35 -------------<61 4.7 21 2.1 - Studies were notable for: NCHCT 1. No evidence of acute intracranial abnormality. 2. Overall similar appearance of extensive paranasal sinus disease as described above, with areas of hyperdensity which may represent inspissated secretions though fungal colonization cannot be excluded Foot x-ray Retrocalcaneal and plantar calcaneal heel spurs, otherwise no findings to account for left heel pain. CXR Retrocalcaneal and plantar calcaneal heel spurs, otherwise no findings to account for left heel pain. - The patient was given: Prehospital ___ 17:29 IV dextrose 10 % Injectable Solution 20 gms BEMS ___ 18:09 IV Dextrose 50% 25 gm ___ 18:48 IVF D5LR ( 1000 mL ordered) On arrival to the floor, the patient and his family confirms the history as above. He generally checks his own BS and administers his own insulin. He notes this AM his sugar was 300 in the AM and gave himself his home degludec 60 U QAM. Prior to lunch, he gave himself 16 units of novolog without checking his sugar, which is does daily. He has never had hypoglycemic episodes before with lowest recorded BS 99. He denies any current chest pain, shortness of breath, nausea, vomiting, diarrhea. He does have ongoing pain in his left heal. Past Medical History: CKD CAD T2DM HLD HTN Anemia, ___ and ICD Cirrhosis with h/o varices Gastric polyps Social History: ___ Family History: Negative for DM, HTN, cancer or heart disease Physical Exam: ADMISSION PHYSICAL ================== GENERAL: Alert and interactive. In no acute distress. HEENT: Sclera anicteric and without injection. MMM. NECK: No appreciable JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, mildly distended and tympanic, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Some mild swelling in left ankle. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL ================== Gen: NAD HEENT: MMM CARDIAC: RR, no m/r/g LUNGS: CTAB, normal WOB ABDOMEN: S, NT, BS+ EXTREMITIES: mild swelling in left ankle. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Stable gait Pertinent Results: ADMISSION LABS ============== ___ 06:07PM BLOOD WBC-7.7 RBC-2.56* Hgb-7.2* Hct-24.2* MCV-95 MCH-28.1 MCHC-29.8* RDW-15.8* RDWSD-54.7* Plt ___ ___ 06:07PM BLOOD Glucose-61* UreaN-35* Creat-2.1* Na-143 K-4.7 Cl-108 HCO3-21* AnGap-14 ___ 05:16AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.6 Mg-2.1 Iron-112 DISCHARGE LABS ============== ___ 06:13AM BLOOD WBC-7.4 RBC-2.52* Hgb-7.2* Hct-23.3* MCV-93 MCH-28.6 MCHC-30.9* RDW-15.2 RDWSD-51.9* Plt ___ ___ 06:13AM BLOOD Glucose-171* UreaN-32* Creat-1.7* Na-140 K-5.0 Cl-108 HCO3-20* AnGap-12 ___ 06:13AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8 RELEVANT IMAGING ================ ___ Left Foot X-ray IMPRESSION: Retrocalcaneal and plantar calcaneal heel spurs, otherwise no findings to account for left heel pain. ___ CT Head w/o Contrast IMPRESSION: 1. No evidence of acute intracranial abnormality. 2. Unchanged paranasal sinus disease containing hyperdense material suggesting inspissated material, difficult to exclude fungal colonization. Brief Hospital Course: ___ y/o M with history of CKD, CHF (LVEF = 47 %), chronic transfusion-dependent anemia disease, CAD, DM, HLD, HTN, cirrhosis who presented with hypoglycemia. TRANSITIONAL ISSUES =================== [] Insulin Regimen at Discharge: Tresiba 26 Units QAM. Prandial Dose: dose of 4 units breakfast/ 6 units lunch/ 4 units dinner for 101-200 range. Thereafter, 2 units increase for every 50 mg/dL increase in FSBG. [] Patient's home Lasix and Losartan were held on discharge due to continued mildly elevated Cr. He should have labs within the next week, and restart these medications if his kidney function improves. [] Consider switching patient's iron to every other day to try to optimize absorption. ACUTE/ACTIVE ISSUES: ==================== #. Hypoglycemia #. IDDM Presented with unresponsiveness in the setting of a blood sugar of 33 at home, which improved with D50 and D5 in the ED. Suspect the etiology of his hypoglycemia was likely over-aggressive insulin regimen in the setting of poor PO intake. There was some suspicion patient accidentally injected himself with an incorrect amount of insulin, but after discussion with his family, they did not appear concerned about this. Other potential contributing factors to his hypoglycemia include ___ on admission which could cause his long-acting insulin to accumulate. Additionally in the setting of his cirrhosis he is more prone to hypoglycemia. He is on propranolol for primary prophylaxis in the setting of varices which could have blunted symptoms of hypoglycemia leading to the profound hypoglycemia and resulting coma. ___ was consulted, and adjusted his regimen to help prevent further hypoglycemia. We educated the patient and his family that from a safety perspective mild/moderate hyperglycemia is much safer, and thus would be preferred, over hypoglycemia. [] Insulin Regimen at Discharge: Tresiba 26 Units QAM. Prandial Dose: dose of 4 units breakfast/ 6 units lunch/ 4 units dinner for 101-200 range. Thereafter, 2 units increase for every 50 mg/dL. #. ___ on CKD Baseline creatinine 1.5, increased to 2.1 on admission. Suspect ___ to poor PO intake I/s/o altered mental status from hypoglycemia, along with diuretic use and anemia. Improved following IVF and transfusion. Lasix and losartan were held in setting of his acute kidney injury. Cr 1.7 on discharge. [] Patient's home Lasix and Losartan were held during hospitalization and on discharge due to continued ___. He should have labs within the next week, and restart these medications if his kidney function improves. #. Left foot pain Patient endorses mechanical fall and twisting of left ankle. X-ray in the ED without fracture. Treated with Tylenol. #. Toxic Metabolic Encephalopathy Patient was unresponsive at home in the setting of his hypoglycemia. Since correction of his glucose his mental status has returned to baseline per the family. He also has no focal deficits on exam. NCHCT was negative for acute intracranial process. No asterixis on exam making HE less likely. Remained at baseline through rest of hospitalization. #. Paranasal Sinusitis Noted incidentally on imaging. Patient without clinic findings or symptoms. Low suspicion for acute infection/fungal invasion. Started on saline nasal spray. CHRONIC ISSUES ============== #. ___ Cirrhosis MELD score 15. Child ___ A. Was continued on home medications without evidence of acute decompensation. #. Anemia Thought most likely secondary to CKD and anemia of chronic disease per outpatient records. Requires intermittent transfusions, most recently getting 2 units in ___, also gets procrit 150,000 units per week I/s/o anemia of chronic. Transfused total of 2 units while inpatient for low Hgb. 1 unit pRBCs on ___ for Hgb 6.2, and 1 unit pRBCs on ___ (pre-transfusion Hgb was 7.2). #. Eosinophila Has a history of eosinophilia dating back to ___. Stable on labs. #. HFmrEF (LVEF = 47 %) #. CAD Euvolemic to dry on exam. Held home Lasix, losartan, and propranolol, as above. [] Plan to resume home lasix in coming days. #. HTN Held losartan due to ___ on admission. Was mildly hypertensive on day of discharge, so expect that as long as his serum Cr returns to baseline, OK to resume home losartan in the coming days. . . . . Time in care: >30 minutes in discharge related activities today. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Losartan Potassium 50 mg PO DAILY 2. Propranolol LA 60 mg PO DAILY 3. Senna 8.6 mg PO DAILY 4. Simvastatin 40 mg PO QPM 5. Ferrous Sulfate 325 mg PO DAILY 6. degludec 60 Units Breakfast Insulin SC Sliding Scale using novolog Insulin 7. Furosemide 40 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever NOT relieved by Ibuprofen 2. Sodium Chloride Nasal ___ SPRY NU QID:PRN runny nose 3. Tresiba 26 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 4. Aspirin 81 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Propranolol LA 60 mg PO DAILY 7. Senna 8.6 mg PO DAILY 8. Simvastatin 40 mg PO QPM 9. Vitamin D ___ UNIT PO DAILY 10. HELD- Furosemide 40 mg PO DAILY This medication was held. Do not restart Furosemide until instructed by your primary care physician 11. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until instructed by your primary care physician 12.Outpatient Lab Work Labs: CBC, ___ Date: ___ ICD-9: 584.9 Contact: ___, phone: ___, fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======= Hypoglycemia SECONDARY ========= ___ Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital due to low blood sugars. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - While here, we had our ___ team adjust your insulin regiment to hopefully prevent further episodes of low blood sugars. WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19829815-DS-8	19,829,815	23,599,879	DS	8	2201-11-30 00:00:00	2201-11-30 18:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: presyncope and lightheadedness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is an ___ with h/o CKD, DMII, HTN, HLD, CAD who presents with an episode of ?presyncope this morning. The patient is mostly ___ and is a poor historian. Most of history was obtained from daughter through a phone call. Pt took all his medications this morning as usual. Per wife, he had ___ out and when he returned home, he slept for a few hours which is unusual for him. Around 1pm, he walked to the garden where he says that sunlight started bothering his eyes and he reported being "dizzy" to the daughter. He was alone in the garden but described this to his daughter: he took a step and fell backwards in the setting of being lightheaded. He leaned on his back and sat down. No LOC. No passing out or hitting his head/body. Daughter went to check on him in the garden. He sat down for a few minutes, drank some water, and felt better. They came back upstairs. He walked up the stairs and did fine. Upstairs, he checked his FSG which was 190's and BP 84/45. He was sitting down in a chair. Daughter noticed that he started "coughing with his whole body" and "clearing his throat". His dentures came out. Throughout this, daughter called his name but he was not responding. Per daughter, he cannot recall this event when his dentures came out. Soon after, pt felt fine and responded. Daughter called EMS but pt questioned why and that he feels fine. Per EMS report, pt had an episode of vomiting on way. Otherwise, patient denies any URI symptoms, fever, chills, dyspnea, chest pain. He reports black stools for over ___ years because he's on iron supplements recommended by his PCP. No BRBPR. In the ED, initial vitals were: 98.5 72 142/48 15 99% on RA. - Labs were significant for H&H 9.___/27.2 (down from 9.8/29.6 on ___, eos 8.4%, BUN/Cr 34/1.9 (baseline Cr 1.7-1.8), bicarb 19, GAP 17. Rectal exam in ED notable for "melenic stool and guaiac positive(although per PCP notes in ___, pt always has dark stool d/t iron supplements). GI evaluated the patient, did not make any urgent recommendations given stable H&H, and will follow when inpatient. EKG with Q waves in inferior leads, LAD, IVCD, flattened T waves in lateral leads. - Imaging revealed: none done in ED. - The patient was given 500mL NS. Vitals prior to transfer were: 97.8 70 134/117 22 100% RA. Upon arrival to the floor, VS are: 98.3 160/80 74 18 95% on RA. Pt denies any chest pain, lightheadedness, malaise, dyspnea, cough, abd pain. No recent changes in BM. Denies palpitations, worsening ___ edema, orthopnea, or PND. Denies any prior history of presyncope/syncope. Pt's cardiologist is at ___. He's never had a heart attack or stroke. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denies arthralgias or myalgias. Past Medical History: CHRONIC KIDNEY DISEASE CORONARY ARTERY DISEASE DIABETES MELLITUS HYPERLIPIDEMIA HYPERTENSION EOSINOPHILIA ANEMIA OF CHRONIC DISEASE ABDOMINAL PAIN CONSTIPATION Social History: ___ Family History: Negative for DM, HTN, cancer or heart disease. Physical Exam: ADMISSION PHYSICAL EXAM: ============================= Vitals: 98.3 160/80 74 18 95% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, 1+ edema above ankles Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM: ============================= Vitals: 98.2 102/57 (102-143/46-73) 60-65 18 97RA FSBG 266, 355, 206 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ADMISSION LABS: ================= ___ 02:35PM BLOOD WBC-9.5 RBC-3.07* Hgb-9.2* Hct-27.2* MCV-88# MCH-30.1 MCHC-34.0 RDW-16.2* Plt ___ ___ 02:35PM BLOOD Neuts-68.8 Lymphs-15.0* Monos-7.2 Eos-8.4* Baso-0.6 ___ 03:22PM BLOOD ___ PTT-27.7 ___ ___ 02:35PM BLOOD Glucose-139* UreaN-34* Creat-1.9* Na-139 K-4.3 Cl-103 HCO3-19* AnGap-21* ___ 05:40AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9 ___ 05:40AM BLOOD ALT-12 AST-19 CK(CPK)-73 AlkPhos-96 TotBili-0.5 ___ 02:35PM BLOOD proBNP-444 ___ 02:35PM BLOOD cTropnT-<0.01 ___ 05:40AM BLOOD CK-MB-2 cTropnT-<0.01 IMAGING: ================= + NCHCT ___: No acute intracranial process. + CXR ___: read pending. + ECG: NSR at 69 bpm, LAD, QTS 138 otherwise normal intervals, Q waves in inferior leads, LAD, IVCD, flattened T waves in lateral leads. + TTE ___ ___): Left Ventricle: The left ventricle is normal in size. There is borderline concentric left ventricular hypertrophy. The visually estimated left ventricular ejection fraction is mildly reduced at 45%. There is global hypokinesis with more pronounced hypokinesis of the inferior wall and inferior septum. Right Ventricle: Normal right ventricular size, wall thickness, and contractility. Left Atrium: Normal left atrial size. Right Atrium: The right atrium is normal in size. Aortic Valve: The aortic valve is tricuspid and mildly thickened. There is no evidence of aortic stenosis. There is trace aortic valve regurgitation. Mitral Valve: The mitral valve is mildly diffusely thickened and there is posterior mitral annular calcification. There is no mitral stenosis. Mild mitral regurgitation is present. Tricuspid Valve: The tricuspid valve is structurally normal. Trace tricuspid valve regurgitation is present. The tricuspid regurgitant velocity is 2.10 m/s, and with an assumed right atrial pressure of 5.0 mmHg, the estimated pulmonary artery systolic pressure is normal at 22.6 mmHg. Pulmonic Valve: There is no obvious pulmonic valve abnormality. There is no pulmonic stenosis. There is trace pulmonary valve regurgitation. Aorta: The aortic root size is normal, measuring 3.40 cm at the sinuses. Pulmonary Artery: The pulmonary artery appears normal in size. Pericardium/Pleura: There is a pericardial fat pad. No significant pericardial effusion is seen. + TTE (___): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no systolic anterior motion of the mitral valve leaflets. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No structural cardiac cause of syncope. Normal global and regional biventricular systolic function. DISCHARGE LABS: =================== ___ 05:40AM BLOOD WBC-8.1 RBC-2.92* Hgb-8.7* Hct-25.7* MCV-88 MCH-29.7 MCHC-33.7 RDW-16.4* Plt ___ ___ 05:40AM BLOOD Neuts-65.2 Lymphs-16.4* Monos-9.0 Eos-9.1* Baso-0.3 ___ 05:40AM BLOOD ___ PTT-33.0 ___ ___ 05:40AM BLOOD Glucose-193* UreaN-40* Creat-1.8* Na-138 K-4.1 Cl-104 HCO3-23 AnGap-15 ___ 05:40AM BLOOD ALT-12 AST-22 AlkPhos-81 TotBili-0.5 ___ 05:40AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.9 Brief Hospital Course: Mr. ___ is an ___ with h/o CKD, DMII, HTN, HLD, CAD who presents with an episode of presyncope on day of admission. # Presyncope: Given pt's reported BP 84/48 and feeling lightheaded during the event, most likely due to hypotension caused by vasodilation induced by sun exposure while outside. However, given his presentation and significant risk factors for cardiovascular disease including DM, HTN, HLD, CAD, a cardiogenic etiology (ACS, CHF, arrhythmia) as well as neurological (CVA, seizure) were considered. Initial differential included meds (though stable vitals on home medications) vs infection (though CXR, UA and Blood cultures without clear evidence of infection) vs. cardiac. Cardiac etiology was concerning given abnormal EKG suggestive of prior inferior MI but no acute ischemic changes and troponin x2 negative. No evidence of arrhythmia on telemetry. TTE with no structural cardiac cause of syncope. Given negative workup, most likely cause was syncope was vasovagal. Should episode occur again would recommend Holter monitoring. # Black stools: Pt was admitted for GI w/u in the setting of presyncope and rectal exam with black stools and guaiac positive. However, ___ and per pt, he's had black stools ___ years now since he's been taking iron supplements. He has history of anemia of chronic disease per PCP note in ___ and H&H has been stable x2 months. # CAD: History is unknown as pt's cardiologist is at ___. However, EKG is evident of inferior MI. He has multiple risk factors for CAD. On aspirin, metoprolol 200mg XL, losartan 50mg, simvastin 80mg daily. These were continued during hospitalization. # DMII: well controlled as most recent A1C in ___ was 6.2. On Lantus and Januvia. # CKD: Cr is at baseline. Most likely d/t hypertension and DMII. # Chronic Eosinophilia: Found to have positive high strongyloides antibody in ___. Treated with Ivermectin with improvement TRANSITIONAL: ================== - Followup with ___ Cardiologist. - Would recommend colonoscopy as no prior studies in our system. - Patient should followup with PCP, ___ recommend checking CBC and renal function at followup. CORE MEASURES: ================== # CODE STATUS: full code confirmed # CONTACT: daughter ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 40 mg PO DAILY 2. Glargine 75 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Losartan Potassium 50 mg PO DAILY 4. Metoprolol Succinate XL 200 mg PO DAILY 5. Omeprazole 40 mg PO BID 6. Simvastatin 80 mg PO QPM 7. Januvia (sitaGLIPtin) 50 mg oral DAILY 8. Aspirin 325 mg PO DAILY 9. Ferrous Sulfate 325 mg PO BID 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Bisacodyl 5 mg PO DAILY:PRN constipation 3. Ferrous Sulfate 325 mg PO BID 4. Furosemide 40 mg PO DAILY 5. Glargine 70 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Losartan Potassium 50 mg PO DAILY 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Simvastatin 80 mg PO QPM 11. Januvia (sitaGLIPtin) 50 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Syncope SECONDARY: Diabetes Mellitus, Coronary Artery Disease, Hypertension, Chronic Eosinophilia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure meeting you and taking care of you. You were admitted for dizziness and lightheadedness after being outside in the sun. We were concerned this was caused by a vaso-vagal episode where you blood pressure temporarily drops and you lose consciousness. We were also concerned that this could have been caused by an infection or heart problem but there was no evidence of any acute infection. We monitored your heart rhythm on telemetry and got an ultrasound of your heart which showed no structural cardiac cause of syncope. Finally we obtained a CT scan of your head which showed no acute intracranial issues. We recommend that you followup with your PCP and cardiologist. We wish you the best, Your ___ team. Followup Instructions: ___
19829995-DS-18	19,829,995	20,758,969	DS	18	2148-11-15 00:00:00	2148-11-18 11:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bilateral leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: This is an ___ year old female with PVD, HLD, vison impairment who presents with a one month history of bilateral ___ redness, and swelling. She endorses that they both have been weeping fluid that she hasn't seen. Patient reports never having a similar episode. She endorses long-standing swelling of bilateral extremities but only recent weeping. Patient denies any trauma, long-haul flights or shortness of breath. She is a non-smoker. Patient does have hx of A.flutter but only on aspirin 81mg once daily and is not currently anti-coagulated. Does not like to go the doctors. ___ time she saw a cardiologist was in ___ in ___ and ___ name was ___. She denies fever, chills, nausea, and vomiting, diarrhoea, constipation, headache, new numbness or weakness. In the ED, initial vs were: 98.9 52 142/57 16 98% RA Labs were remarkable for a BUN of 65 and creatinine of 2.0. Patient was given one dose of vancomyin 1g IV/nafcillin 1g IV Vitals on Transfer:98.9 52 142/57 16 98% RA On the floor, vs were: T98.1 P63 BP150/70 R16 92%O2 sat Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: 1ST DEGREE AV BLOCK HYPERLIPIDEMIA minimal vision od HYPERTENSION OPEN ANGLE GLAUCOMA ATRIAL FLUTTER CATARACT SENILE GLAUCOMA HYPERCHOLESTEROLEMIA Social History: ___ Family History: n/c Physical Exam: ADMISSION EXAM: Vitals: T98.1 P63 BP150/70 R16 92%O2 sat General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: mild expiratory wheeze auscultate throughout CV: Iregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Bilateral erythema. No open wounds. Neuro: A and O to name, place but not date. No pronator drift. Power ___ in all four extremities. DISCHARGE EXAM: Vitals: T97.8 P58 BP144/47 R22 O2 sat 98% RA (92-98%RA) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: mild expiratory wheeze auscultate throughout, mild crackles at bases bilaterally CV: Iregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, 2+ edema. Skin: Bilateral erythema. No open wounds. Wrapped in compression bandages. Neuro: AOx3. Pertinent Results: ADMISSION LABS: ___ 11:34AM BLOOD WBC-8.1 RBC-4.60 Hgb-14.3 Hct-45.2 MCV-98 MCH-31.0 MCHC-31.5 RDW-12.7 Plt ___ ___ 11:34AM BLOOD Neuts-67.8 ___ Monos-7.2 Eos-1.2 Baso-0.8 ___ 11:34AM BLOOD ___ PTT-33.9 ___ ___ 11:34AM BLOOD Glucose-134* UreaN-65* Creat-2.0* Na-139 K-4.9 Cl-99 HCO3-28 AnGap-17 ___ 11:34AM BLOOD proBNP-2093* ___ 09:30PM BLOOD CK-MB-4 cTropnT-0.03* ___ 09:30PM BLOOD Albumin-3.6 ___ 11:34AM BLOOD TSH-1.4 URINE: ___ 09:22AM URINE Color-Straw Appear-Clear Sp ___ ___ 09:22AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 05:30PM URINE Hours-RANDOM UreaN-408 Creat-35 Na-100 K-27 Cl-99 ___ 05:30PM URINE Osmolal-398 DISCHARGE LABS: ___ 05:45AM BLOOD WBC-7.0 RBC-4.19* Hgb-13.3 Hct-40.8 MCV-98 MCH-31.8 MCHC-32.6 RDW-12.9 Plt ___ ___ 12:50PM BLOOD ___ PTT-30.9 ___ ___ 12:45PM BLOOD Glucose-139* UreaN-60* Creat-2.0* Na-141 K-4.4 Cl-98 HCO3-28 AnGap-19 REPORTS: ECHO ___: The left atrial volume is mildly increased. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Mild aortic regurgitation. Mild mitral regurgitation. Moderate pulmonary hypertension. CXR ___: The lung volumes are normal. Moderate scoliosis causes slight asymmetry of the rib cage. Tortuous thoracic aorta. Borderline size of the cardiac silhouette without pulmonary edema and pneumonia. Calcified valvular annulus projecting over the cardiac silhouette. CXR ___: No evidence of acute heart failure or volume overload. Bilat Lower Extremity Ultrasound ___: IMPRESSION: 1. No evidence of deep vein thrombosis in the bilateral proximal lower extremities. 2. Significant soft tissue edema within the distal lower extremities precluding evaluation of the perineal and posterior tibial veins. Brief Hospital Course: This is an ___ year old female with PVD, HLD, vison impairment who presented with a one month history of bilateral lower extremity redness and swelling. ACTIVE MEDICAL ISSUES #BILATERAL LEG SWELLING: Patient presented with a one month history of bilateral leg swelling and redness, up to her knees. In the ED LENIs study ruled out DVT's, and patient was given one dose of nafcillin and vancomycin for possible cellulitis. However, on clinical exam this appeared not to be cellulitic and rather likely secondary to acute on chronic venous stasis dermatitis, and possibly also secondary to heart failure. On the floor, patient slept with legs elevated above the level of the heart, wore ACE compression bandages, and used topical triamcinilone and emollient therapy as barrier protection. She had workup and treatment for CHF as below. By discharge leg pain and swelling had significantly improved. #CHF: Given peripheral lower extremity edema and chronic venous insufficiency, it is likely that the patient has some degree of diastolic heart failure. She has an outpatient cardiologist, Dr. ___ in ___, but she has not seen him since ___. Here workup was done for heart failure that included elevated BNP (___) and Echo that showed normal ejection fraction but moderate pulmonary hypertension and dilated right and left atria. It is possible that she has diastolic heart failure with a normal ejection fraction. Chest X ray on admission showed ___ B lines suggesting volume overload, so patient was started on IV Lasix for diuresis. O2 sats improved and follow up chest X ray showed no signs volume overload. Her weight decreased four kilograms from admission to discharge, as she was likely fluid overloaded when she came in. Discharge weight 66kg. Patient worked with ___ and desaturated to 90 on ambulation. This was felt to be most likely due to her known COPD and she had a history of refusing home O2 for this in the past. She unfortunately refused home oxygen despite the risk of worsening lung disease and other serious consequences. We arranged close follow up with her PCP and outpatient cardiologist. #CKD vs ___: The patient had no documentation of previous values of creatinine until ___. Creatinine at admission was 2.0 compared to baseline creatinine 1.5. This was likely in the setting of dehydration vs poor forward flow from CHF. FeNa was 4% making prerenal less likely, however this was in setting of diuretics which could mask prerenal. FeUrea was 3.8%. All medications were renally dosed, and her lisinopril was held. Creatinine remained stable at 2.0 during this hospital stay. CHRONIC MEDICAL ISSUES #Atrial flutter: No acute issues this hospitalization. Patient had documented previous atrial flutter and has a CHADS 2 score of at least 2 (given her age and history of hypertension). Per outpatient cardiology notes, she is not anticoagulated given fall risk due to decreased vision. She is on aspirin 81mg daily and diltiazem 180 for rate control. Patient was continued on home medications with no acute events. #HYPERLIPIDEMIA: No acute issues this hospitalization. Patient was continued on home dose simvastatin 20mg once daily. TRANSITIONAL ISSUES: []consider PFTs as outpatient []consider increasing lasix if worsening of leg swelling []please ensure patient elevates legs above level of heart three times a day []consider discussion of home O2 with patient as she was not keen on this as inpatient []discharge weight 66kg (admission weight 72.6kg) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Diltiazem Extended-Release 180 mg PO DAILY 3. Simvastatin 40 mg PO DAILY 4. Furosemide 80 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Potassium Chloride 20 mEq PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Diltiazem Extended-Release 180 mg PO DAILY 3. Simvastatin 40 mg PO DAILY 4. Hydrocerin 1 Appl TP BID RX white petrolatum-mineral oil [Eucerin] please apply to legs twice a day twice a day Disp #1 Bottle Refills:0 5. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID RX triamcinolone acetonide 0.025 % please apply to legs twice a day Disp #1 Bottle Refills:0 6. Furosemide 80 mg PO DAILY 7. Lisinopril 40 mg PO DAILY 8. Potassium Chloride 20 mEq PO DAILY Hold for K > 5 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Venous insufficiency Secondary: HYPERLIPIDEMIA,HYPERTENSION, Atrial flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms ___, It was a pleasure having you here at the ___ ___. You were admitted here with bilateral leg swelling and tightness. You had an ultrasound of both your legs done to rule out any clots in your leg. Your leg swelling was thought to be from poor circulation in the veins and poor function of your heart. Your leg swelling improved after you raised your legs above the level of your heart and had them bandaged up. You also received intravenous doses of your water pill (Lasix) which helped you get rid of some of the excess water accumulated in your legs. Please keep your follow up appointments below. We wish you the very best, Your ___ medical team Followup Instructions: ___
19829995-DS-19	19,829,995	21,334,840	DS	19	2149-02-08 00:00:00	2149-02-08 16:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bilateral leg edema, erythema, and pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with PVD, HLD, HTN, and CHF (preserved EF > 55%), vison impairment who presents with a one month history of bilateral ___ redness, and swelling x 1 month. Pt presents from assisted living (___) for evaluation of bilateral lower extremity redness, swelling and weeping, which has been ongoing for ___ months. She was admitted ___ for the same issue, ruled out with negative LENIs, treated with topical triamcinolone and ace wrap, improved and then discharged. The patient states that at home, she did not have any nurses come by to put anything on her legs other than compression stockings. Her legs now have gotten much more painful, and interferes with her walking and with dressings. She denies fevers and chills. Patient has had no SOB, cough, or chest pain. States normal urination and bowel movement. In the ED initial vitals were: 97.8 64 146/47 20 95%. Exam was signficant for beefy red and tender legs bilaterally with surrounding scale, DP pulses palpable. Lung sounds with rales to left lower lobe. Labs were significant for WBC 10.7 with 75.9% neutrophils, stable h/h and creatinine of 2.2 above baseline. Lactate was 1.9. CXR was obtained and was negative. Patient was given IV vancomycin and ceftriaxone. Vitals prior to transfer were:97.7 78 140/72 20 94% RA. This AM, she states that her legs are not in pain but that the pain waxes and wanes without a pattern. She denies SOB, DOE, PND, orthopnea or cough. Past Medical History: 1. 1st Degree AV block 2. Hyperlipidemia 3. Minimal vision OD 4. Hypertension 5. Open Angle Glaucoma 6. Atrial flutter 7. Cataract 8. Chronic Kidney Disease 9. Heart Failure with Preserved EF (EF 55%) 10. ?Chronic COPD, no PFTs Social History: ___ Family History: n/c Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - T: 98.9 BP: 143/50 HR: 74 RR: 20 02 sat: 98% RA. Weight 64.2kg (last discharge weight 66.0kg) GENERAL: Pleasant elderly female in NAD, alert and oriented, speaking in full sentences HEENT: EOMI, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition NECK: nontender supple neck, no LAD, no appreciable JVD CARDIAC: Iregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops LUNG: mild expiratory wheeze auscultate throughout, mild crackles at bases bilaterally otherwise clear to auscultation bilaterally ABDOMEN: Ventral hernia, otherwise nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: ___ ___ edema, beefy red legs with crusts, scale and areas which are weeping serous fluid. Venous staiss changes noted bilaterally with areas of hyperpigmentation. No purulence noted. moving all extremities well, no cyanosis, clubbing. PULSES: 2+ DP pulses bilaterally NEURO: Speech coherent, cognition intact, CN III-XII grossly intact (patient is blind). Moving all four extremities DERMATOLOGY EXAM ___: Total body skin examination including general appearance, face, neck, chest, back, abdomen, extremities and groin was performed. Pertinent positive findings are listed below: In general, well developed, well nourished, A&O X3, NAD Overall, xerotic Legs with inverted champagne bottle appearance 1+ edema below the knee with some woody induration distally Below the knees, shins > calfs, with erythematous plaques with adherant scale. Distally, there is adherant scale crust. Soles with mild erythema with scaling No interdigital maceration First L toe with mild onycholysis with subungal debris No ulcerations DISCHARGE PHYSICAL EXAM: Vitals: 97.5/97.5 m130/50 55 20 98% RA GENERAL: NAD, sleeping HEENT: EOMI, anicteric sclera, pink conjunctiva, patent nares, mucous membranes moist, left eye with skin irritation but no crusting this AM CARDIAC: Iregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops LUNG: CTAB ABDOMEN: Ventral hernia, otherwise nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Trace ___ edema, beefy red legs with crusts, scale, Now wrapped with ACE. PULSES: 2+ DP pulses bilaterally NEURO: Speech coherent, cognition intact, CN III-XII grossly intact (patient is blind in right eye). Moving all four extremities. Sensation to light touch intact in bilateral feet. SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 09:30PM BLOOD WBC-10.7# RBC-4.81 Hgb-14.7 Hct-46.3 MCV-96 MCH-30.6 MCHC-31.8 RDW-12.5 Plt ___ ___ 09:30PM BLOOD Neuts-75.9* Lymphs-13.8* Monos-8.3 Eos-1.7 Baso-0.4 ___ 09:30PM BLOOD Glucose-132* UreaN-95* Creat-2.2* Na-139 K-5.1 Cl-98 HCO3-26 AnGap-20 ___ 09:30PM BLOOD proBNP-1539* ___ 10:58PM BLOOD Lactate-1.9 DISCHARGE LABS: ___ 06:20AM BLOOD WBC-13.7* RBC-4.28 Hgb-12.8 Hct-41.3 MCV-97 MCH-30.0 MCHC-31.1 RDW-12.6 Plt ___ ___ 06:00AM BLOOD Glucose-137* UreaN-81* Creat-1.8* Na-139 K-4.9 Cl-101 HCO3-28 AnGap-15 MICROBIOLOGY: ___ URINE CULTURE NEGATIVE ___ BLOOD CULTURE NEGATIVE ___ BLOOD CULTURE NEGATIVE Brief Hospital Course: ___ year old female with PVD, HLD, HTN, and HFPEF, vison impairment who presents with a one month history of bilateral ___ redness, and swelling for the past few months. Active Issues: # Bilateral lower extremity edema, erythema, and pain: Unlikely cellulitis given that it is bilateral, symmetric and well demarcated and no evidence of purulent drainage. Per Dermatology consult, her skin findings are likely "venous stasis dermatitis with early lipodermatosclerosis. She also has mild tinea pedis with evidence of onychomycosis. The redness and scaly plaques can be attributed to her stasis dermatitis and not a cellulitis. Pain can be attributed to lipodermatosclerosis. We would like to treat her tinea pedis as to prevent cellulitis. Stasis dermatitis and lipodermatosclerosis are chronic and progressive conditions that need continued care. We thus agree that the patient receive additional assistance at home." They recommended compression daily, fluocinonide BID to affected areas x 2 weeks/month max, emollients such as vaseline or hydralatum, leg elevation whenever possible. For pain they recommended topical capsaicin cream three to four times daily for pain relief. The patient will follow up in ___ clinic, where she can get qweekly UNA boots placed and where they can continue to help with mgmt of topical medications. # Tinea pedis: Dermatology recommended econazole QD to the feet to treat fungal infection and to prevent nidus of bacterial entry for cellulitis. # Acute on chronic renal failure: Patient has a baseline Cr of ~2. She received IV lasix on arrival. Admission weight was 64 kg from last discharge weight of 66 kg. Cr then rose to ~3, likely prerenal. She received gentle IV fluids and was encouraged to hydrate. On discharge Cr was 1.8, at baseline. Additionally, given CKD, the patient was started on a low potassium (2gm per day) diet. Home lisinopril and lasix were held initially, and upon discharge, lasix 40mg daily was restarted but home lisinopril was stopped. PCP can decide if/when to restart home lisinopril. # Left eye conjunctivitis: Patient had redness and crusting in her left eye, so was started on erythromycin eye drops QID x 5 days. Last day will be ___. # Dispo planning: Patient has multiple active meds on file but states she only takes 4 meds - aspirin, statin, lasix, and one other med she does not remember. She is blind in right eye and has reduced functional ability. Physical therapy and Occupational therapy evaluated the patient and recommended rehab since the patient could not independently transfer/walk and cannot self-care. # Urinary retention: After patient had received oxycodone for 2 days, she had urinary retention and was straight cathed for 750cc urine. Oxycodone was stopped since leg pain improved with better topical care, and patient's urinary retention resolved. Chronic Issues: # Heart failure with preserved EF: Recent ECHO showed normal ejection fraction of 55%, moderate pulmonary hypertension and dilated right and left atria. Has been seen by cardiology in the past and has had an elevated BNP. CXR without evidence of volume overload and patient did not have exam findings of fluid overload. On discharge, the patient was on half of home lasix dose and lisinopril was stopped given ___. It can be restarted on an outpatient basis. # Atrial flutter: Patient has documented previous atrial flutter and has a CHADS 2 score of at least 2 (given her age and history of hypertension). Per outpatient cardiology notes, she is not anticoagulated given fall risk due to decreased vision. She was continued on home aspirin 81mg daily and home diltiazem ER 180 for rate control. # Hyperlipidemia: Continue on home dose simvastatin 20mg once daily Transitional Issues: # Venous stasis dermatitis and wound care: Dermatology recommended compression daily, fluocinonide BID to affected areas x 2 weeks/month max, emollients such as vaseline or hydralatum, leg elevation whenever possible. For pain they recommended topical capsaicin cream three to four times daily for pain relief. She should also continue ACE wraps or compression stockings and elevation of her legs as much as possible. Followup with Dermatology scheduled for ___. # Tinea pedis: Per Dermatology, she was started on clotrimazole cream BID. # Vascular surgery outpatient appointment was made for full venous insufficiency workup and for ABI and peripheral vascular disease workup. It is on ___. # A1C 6.6: We noted the patient's glucose to be mildly elevated in ~120s while inpatient. A1C qualifies as diabetes. Unclear if the patient would be compliant with diabetic medications, and she is not a good candidate for metformin given CKD. This is an issue that can be further addressed with the patient's PCP. # Simvastatin dose decreased to 10mg daily given risk of myopathy with concurrent administration with diltiazem. # Diltiazem ER dose decreased to 120mg daily from 180mg daily since patient's heart rate was borderline at ___ while inpatient. # Lasix was restarted prior to discharge at a decreased dose of 40mg daily given the patient's ___ while inpatient. Pending continued Cr values, the PCP can consider increasing it back to prior dose of 80mg daily. Lisinopril was stopped given ___ and PCP can decide when/if to restart it. # Left eye conjunctivitis: Please continue erythromycin drops until ___. # Code: DNR/DNI (confirmed) # Communication: No family communication per the patient. Her emergency contact is a friend: ___ BERIL SHEIF Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Diltiazem Extended-Release 180 mg PO DAILY 3. Simvastatin 40 mg PO DAILY 4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID 5. Furosemide 80 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Potassium Chloride 10 mEq PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Diltiazem Extended-Release 120 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Simvastatin 10 mg PO DAILY 5. Acetaminophen 650 mg PO TID 6. Artificial Tears Preserv. Free ___ DROP LEFT EYE PRN redness, irritation 7. Capsaicin 0.025% 1 Appl TP TID to bilateral legs 8. Clotrimazole Cream 1 Appl TP BID to feet 9. Docusate Sodium 100 mg PO BID:PRN constipation 10. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID 11. Fluocinonide 0.05% Cream 1 Appl TP BID to legs Duration: 2 Weeks 12. Hydrocerin 1 Appl TP BID:PRN dry skin 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. Senna 17.2 mg PO BID:PRN constipation 15. Potassium Chloride 10 mEq PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Bilateral venous stasis dermatitis Lipodermatosclerosis SECONDARY DIAGNOSES Left eye conjunctivitis Deconditioning Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had increased pain, swelling, and redness in your legs. You were evaluated by the Dermatologists who recommended continuing daily compression and creams to your legs. These creams include fluocinonide (a steroid), hydrocerin (a moisturizing lotion), and capsaicin (to relieve pain). You were discharged to rehab so that nurses there can continue to care for your legs and so that you can get your strength back again. Additionally, while you were hospitalized, your kidney function got slightly worse. This improved with hydration and some IV fluids. It was a pleasure to take care of you during your hospital stay. We wish you the best, Your ___ Team Followup Instructions: ___
19830154-DS-10	19,830,154	28,886,750	DS	10	2178-01-16 00:00:00	2178-01-18 13:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right sided numbness and neck pain Major Surgical or Invasive Procedure: N/A History of Present Illness: The patient is a ___ woman with a past medical history of recent bilateral cerebellar infarcts with bilateral vertebral artery dissections on warfarin and Lovenox who presents with new right face and torso numbness. On ___, patient awoke with a stiff neck. She denied any antecedent neck manipulation or ___ or neck injury. She massaged her neck and applied heat and took Aleve. On ___, ___, she noted a sense of "fogginess" while driving. Then, when walking, she felt a sense of disequilibrium like "walking on a floating deck on water." She went to her primary care doctor where her systolic blood pressure was in the 190s and she was referred to the emergency department at ___. At ___, she was found to have bilateral vertebral artery dissections and an MRA of the brain revealed bilateral cerebellar embolic appearing infarcts. She was discharged on ___ with Lovenox and Coumadin. After her discharge, on ___, she noted new onset bilateral blurry vision. She continued to have a sense of disequilibrium at rest that worsened when walking; however, the symptoms were gradually improving. On ___, she felt anxious while cooking and felt like her heart was "accelerated" so she re-presented to ___. ___. She was transferred to ___ where she had a repeat CTA ___ and neck which showed stable dissections and an MRI of the brain that did not reveal any new infarcts. She was discharged on ___. On the day prior to presentation, ___, she went to her PCP and had her INR checked. She reports that her INR was low so her PCP recommended she double her warfarin from 5 mg daily to 10 mg daily. On the morning of presentation, she awoke with severe right neck and shoulder pain. She also noted new right face and arm numbness that had never happened prior. She also intermittently felt sensation of someone squeezing in her right shoulder. Symptoms would occur randomly both at rest and with exertion and nothing made her symptoms better or worse. She continues to have a sense of disequilibrium that is worse when she stands and walks. She denies missing any recent doses of her warfarin or Lovenox and denies any recent falls or ___ injury. She initially presented to ___ today where she had a CT angiogram that showed a mildly worse right vertebral artery dissection compared to prior. Her left vertebral artery dissection was slightly improved. She was then transferred to ___ for further management. On neurologic review of systems, the patient denies lightheadedness or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, diplopia, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness. On general review of systems, the patient denies fevers, chest pain, palpitations, cough, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria or rash. Past Medical History: Recent bilateral cerebellar infarctions with bilateral vertebral artery dissections as listed in HPI. Asthma H. pylori Patient does not a have a history of blood clots or connective tissue disorder that she is aware of Social History: ___ Family History: Patient denies a family history of stroke at a young age, blood clots, connective tissue disorders, or autoimmune disorders. Physical Exam: ============== ADMISSION EXAM ============== Vitals: 99.1 78 127/87 14 100% RA General: NAD, resting in bed HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes, sclerae anicteric ___: RRR Pulmonary: CTAB Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - Mental Status - Awake, alert, oriented to person, place and time. Attention to examiner easily maintained. Recalls a coherent history. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling. EOMI, no nystagmus. Decreased sensation to light touch in the right hemi-face at about 50%. No facial movement asymmetry. Hearing intact to finger rub bilaterally. No dysarthria. Palate elevation symmetric. Trapezius strength ___ bilaterally. Tongue midline. - Motor - Normal bulk and tone. Downward drift in the right arm. No tremor or asterixis. Delt Bic Tri WrE FFl FE IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 R 5 ___ 5 4+ 5 5 5 5 5 5 - Sensory - Decreased sensation to pinprick in the right arm and torso sparing the leg at about 50%. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response mute bilaterally. - Coordination - Overshoot is present with finger-nose-finger testing bilaterally. There is some clumsiness with finger tapping bilaterally. - Gait - Patient is able to ambulate independently but is hesitant and takes short steps. ============== DISCHARGE EXAM ============== VS: Tc:98.1 BP:(117-136)/(67-82) ___ RR:16 O2:99RA -GEN: Awake, sitting in chair, NAD -HEENT: NC/AT -PULM: breathing comfortably on room air -EXT: Warm Neurologic - MS: Awake, alert. Able to converse without difficulty. Able to follow commands. - Cranial Nerves - PERRL 3->2 brisk. EOMI, no nystagmus. No facial movement asymmetry. - Motor - Normal bulk and tone. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 5 - 5 5 5 5 - - R 5 ___ 5 5 - 5 5 5 5 - - - Sensory - Decreased sensation to pinprick in the right arm and face ~50%. Slightly decreased sensation to pinprick on right leg ~80-90% - Coordination - Dysmetria with finger nose finger bilaterally R>L. Pertinent Results: ==== LABS ==== ___ 02:30PM BLOOD WBC-6.5 RBC-4.46 Hgb-13.6 Hct-39.4 MCV-88 MCH-30.5 MCHC-34.5 RDW-11.6 RDWSD-37.3 Plt ___ ___ 06:00AM BLOOD WBC-6.0 RBC-4.20 Hgb-12.6 Hct-37.2 MCV-89 MCH-30.0 MCHC-33.9 RDW-11.7 RDWSD-37.6 Plt ___ ___ 06:50AM BLOOD WBC-5.4 RBC-4.31 Hgb-13.0 Hct-37.7 MCV-88 MCH-30.2 MCHC-34.5 RDW-11.6 RDWSD-37.3 Plt ___ ___ 02:30PM BLOOD Neuts-56.9 ___ Monos-5.1 Eos-2.0 Baso-0.6 Im ___ AbsNeut-3.69 AbsLymp-2.26 AbsMono-0.33 AbsEos-0.13 AbsBaso-0.04 ___ 02:30PM BLOOD ___ PTT-34.2 ___ ___ 06:00AM BLOOD ___ PTT-35.4 ___ ___ 06:50AM BLOOD ___ PTT-34.4 ___ ___ 02:30PM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-139 K-3.7 Cl-103 HCO3-23 AnGap-17 ___ 06:00AM BLOOD Glucose-86 UreaN-11 Creat-0.6 Na-137 K-4.3 Cl-101 HCO3-23 AnGap-17 ___ 06:50AM BLOOD Glucose-84 UreaN-12 Creat-0.7 Na-138 K-4.4 Cl-102 HCO3-23 AnGap-17 ___ 06:00AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.4 ___ 04:30PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 04:30PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-8 ======= IMAGING ======= - ___ OSH CTA R vertebral artery dissection appears worse, which now starts more proximally at the C7 level and extends to the C3 level w/ areas of moderate to severe focal narrowing. Left vertebral artery dissection at the C1 level appears slightly improved since prior studies with persistent mild to moderate narrowing. No intracranial aneurysms, stenosis or occlusions identified - ___ MR ___ w/o contrast 1. Left cerebellar and occipital, likely embolic, late acute infarcts as described. 2. Sinus disease. - ___ MRI cervical spine w/o contrast 1. Mild degenerative disc disease at C5-6. No spinal canal or neural foraminal narrowing. 2. Normal caliber signal intensity of the visualized spinal cord. No cord compression. 3. Multifocal narrowing and surrounding T1 hyperintense signal of the right V2 segment, consistent with known dissection. Known left distal V2/V3 segment dissection is excluded from the fat-suppressed axial T1 weighted images. 4. 14 x 16 mm proteinaceous or hemorrhagic nodule in the right lobe of the thyroid may represent a large colloid cyst, but is incompletely evaluated. Further evaluation with ultrasound is recommended if not performed already. - ___ Ultrasound Renal Artery Unremarkable renal ultrasound. No evidence of renal artery stenosis. Brief Hospital Course: Ms. ___ presented to an OSH with right sided numbness and neck pain where a CTA revealed worsening of her R vertebral artery dissection. She was transferred to ___ for further management. MRI ___ showed left cerebellar and occipital late acute infarcts. Her examination was notable for decreased sensation to pinprick on the right face, arm, and leg, as well as, cerebellar signs. Additionally, she had marked tenderness to palpation of the right trapezius and muscles of the neck. Other than hyperextensibility of both fifth fingers and being able to place most of her hands on the ground when standing with her knees locked, she did not have other joint hypermobility. There is no clear evidence of a connective tissue disease such as Ehlers Danlos type IV or Marfan's disease. Etiology of her dissections is unclear, as no history of trauma could be recalled. However, her dissections are in the most common (and mobile) location along the course of the vertebral arteries. Renal artery Doppler done to look for evidence of fibromuscular dysplasia was negative. Etiology of her new right sided symptoms also remains unclear, but may be due to a small infarct in the brainstem that was not detected by MRI brain, muscle spasm and inflammation affecting cutaneous sensory nerves, secondary migraine headache, or anxiety/somatization. MRI of cervical spine was normal, other than noting mild degenerative disc disease at C5-6. # BILATERAL VERTEBRAL DISSECTIONS: Brief review of course: She initially presented to ___ ED on ___nd dysequilibrium and had SBP in 190s. On ___ she re-presented to ___, was found to have bilateral dissections, and was started on Coumadin with a Lovenox bridge. On ___ she presented to ___ due to anxiety; MRI showed stable dissections. On ___ her PCP increased her ___ from 5 to 10mg due to a still subtherapeutic INR. On ___ she presented to St. ___ with the present symptoms of right neck pain, and right face/arm numbness. CTA showed worsened right dissection so she was transferred to ___. Her previous management was continued. Assessment of etiology as above. - Continue Coumadin 10mg DAILY. Goal INR ___. - Plan to recheck INR tomorrow (___). If not within goal of ___, recheck on ___. - PCP ___ further manage Coumadin when INR within goal, then stop Lovenox. - Patient was referred to call our neuro-geneticist, Dr. ___ ___ (___), to schedule an appointment to work-up possible connective tissue disease. # CEREBELLAR STROKES, # LEFT OCCIPITAL STROKES: Etiology likely embolic secondary to vertebral dissections. - Continue anticoagulation as above. - Follow-up scheduled with stroke neurology (Drs. ___ and ___ on ___. - Home ___ # NECK PAIN: Secondary to dissections. Also likely triggering more diffuse muscle tension and back pain, as well as possible secondary neuropathic phenomena and/or migraine headaches. - Avoid NSAIDs since already on dual anticoagulation. - Acetaminophen 650mg Q4H PRN. - Prescribed capsaicin cream TID PRN. - Prescribed Flexeril 10mg BID PRN. - Prescribed lidocaine 5% patches DAILY PRN. - Given soft collar to wear at night. # THYROID NODULE: On MRI of the cervical spine an incidental but large thyroid nodule was seen, measuring 14x16mm and appearing proteinaceous or hemorrhagic. Radiology recommended ultrasound follow-up. - Refer to PCP for thyroid ultrasound. Transitional Issues ==================== - Ultrasound for further evaluation of 14 x 16 mm right thyroid nodule = = = = = = = ================================================================ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? () Yes - (x) No (Done at outside hospital, within normal.) 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 10 mg PO DAILY16 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 4. Montelukast 10 mg PO DAILY 5. Enoxaparin Sodium 80 mg SC BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. Capsaicin 0.025% 1 Appl TP TID:PRN Pain RX capsaicin 0.025 % appl to affected area TID:PRN Refills:0 3. Cyclobenzaprine 10 mg PO TID:PRN Back, Neck pain RX cyclobenzaprine 5 mg 1 tablet(s) by mouth BID:PRN Disp #30 Tablet Refills:0 4. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Back, Neck pain RX lidocaine 5 % apply to affected area daily:PRN Disp #30 Patch Refills:*0 5. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 6. Montelukast 10 mg PO DAILY 7. ProAir HFA (albuterol sulfate) 90 unit inhalation Q4H:PRN SOB 8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 9. Warfarin 10 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Cerebellar stroke Cervical radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of right sided numbness and neck pain initially concerning for stroke. You had an MRI, which showed a new stroke affecting the portion of the brain that controls balance, as well as, the region that affects vision. The stroke resulted from a blood vessel that provides oxygen and nutrients to the brain to be blocked by a clot. The numbness and neck pain you've been experiencing; however, is unrelated to the stroke. The cause of your symptoms is not entirely clear, but may be due to muscle tension. - Please wear your soft cervical collar at night when sleeping - continue to use heat to soften these muscle Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
19830154-DS-11	19,830,154	28,118,676	DS	11	2178-04-11 00:00:00	2178-04-11 15:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: clindamycin Attending: ___ Chief Complaint: headache, neck pain Major Surgical or Invasive Procedure: N/A History of Present Illness: The pt is a ___ year-old F w/ PMH of b/l vertebral dissections c/b multiple CVAs in ___ and Asthma who presents from OSH due to concern for progressing R vertebral dissection in setting of worsened headache sx. Hx obtained from pt and mother at bedside. Pt reports acute onset of severe throbbing pain over L posterior occiput at 2pm which lasted for 1 hour and then spontaneously resolved, followed by reappearance of similar headache over R posterior occiput, with pain radiating down her R arm into fingers. This pain gradually evolved into a pressure-like sensation that intermittently spread up to her vertex, feeling like "hot oil dripping over my head". Associated with this pain was mild intermittent L sided chest pain and "rocking on a boat" sensation. She called her PCP who recommended going to OSH ED. Upon arrival to OSH ED, she also started developing a squeezing R frontal headache, waxing and waning in nature as well as mild nausea. These latter sx improved with administration of Tylenol and Zofran. While in the ED, around 10pm she started noticing visual changes characterized by things becoming "fuzzy" and moving in her vision, worse in L eye. She underwent CTA H&N which was concerning for worsening R vertebral dissection. Pt's outpt neurologist (Dr. ___ who recommended pt be transferred to ___ for further management. Pt denies any clear diplopia, room-spinning sensation, dysarthria, or dysphagia. No new focal numbness or weakness. States she had some chills earlier this week but no fevers or other infectious sx. No recent head trauma or falls. She reports that her Warfarin was recently decreased to 10mg from 15mg due to INR being elevated up to 4 last week, with follow up levels downtrended to 0.8 this ___. She reports her INR level is known to fluctuate and has required her to stay intermittently on Lovenox despite being so far out from last noted stroke. Pt was initially admitted to ___ from ___isequilibrium, and elevated BP to 190s with imaging showing b/l vertebral artery dissections and b/l cerebellar embolic appearing infarcts. She was discharged at that time on Lovenox bridge to Warfarin. She was admitted soon after on ___ to ___ for increased anxiety and repeat workup which showed only stable dissections. On ___, she developed R neck pain and R face/arm numbness for which she managed at ___ with CTA showing worsening R vertebral artery dissection and MRI showing new L cerebellar/occipital infarcts. She was discharged on ___ with same anticoagulant plan of care, soft C-Collar to wear at night, and follow up with Dr. ___ to evaluate for underlying connective tissue disease (pt reports that genetic testing has been sent out but no results as of yet). Neurologic and General ROS negative except as noted above Past Medical History: Recent bilateral cerebellar infarctions with bilateral vertebral artery dissections as listed in HPI. Asthma H. pylori Patient does not a have a history of blood clots or connective tissue disorder that she is aware of Social History: ___ Family History: Patient denies a family history of stroke at a young age, blood clots, connective tissue disorders, or autoimmune disorders. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 97.4 P: 70 BP: 138/96 RR: 18 O2sat: 99% RA General: Awake, cooperative, in mild distress. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, discomfort over R posterior occiput, some neck stiffness Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ in R, ___ in L. bilaterally. V: Decreased sensation to LT over R V1-V3 (60%). VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 4+ ___ ___ 4* 5 5 5 5 5 5 limited by pain -Sensory: Decreased sensation to LT and PP over R anterior shin (60%) in circular distribution from knee to ankle as well as in R lateral forearm roughly approximating C5 distribution(70%). No deficit to proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor or dysdiadochokinesia noted. No dysmetria on FNF or toe to finger bilaterally. -Gait: Deferred. DISCHARGE PHYSICAL EXAM Vitals within normal limits General: Awake, cooperative, in mild distress. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, discomfort over R posterior occiput, some neck stiffness Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. +occipitalis and trapezius muscle tightness and tenderness to palpation Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to examiner. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V. Decreased sensation over the right forehead (60-70% of normal) otherwise intact throughout the face VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 4+ ___ ___ 4* 5 5 5 5 5 5 limited by pain -Sensory: Decreased sensation to LT and PP over R anterior shin (60%) in circular distribution from knee to ankle as well as in R lateral forearm roughly approximating C5 distribution(70%). No deficit to proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor or dysdiadochokinesia noted. No dysmetria on FNF or toe to finger bilaterally. -Gait: Deferred. Pertinent Results: LABORATORY DATA ___ 06:00AM BLOOD WBC-4.5 RBC-4.23 Hgb-12.7 Hct-37.1 MCV-88 MCH-30.0 MCHC-34.2 RDW-11.9 RDWSD-38.2 Plt ___ ___ 06:00AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-141 K-4.2 Cl-107 HCO3-24 AnGap-14 ___ 06:00AM BLOOD ALT-12 AST-12 LD(LDH)-118 CK(CPK)-49 AlkPhos-29 TotBili-0.2 ___ 06:00AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 07:45PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 06:00AM BLOOD TotProt-6.5 Albumin-4.3 Globuln-2.2 Cholest-154 ___ 06:00AM BLOOD %HbA1c-4.7 eAG-88 ___ 06:00AM BLOOD Triglyc-60 HDL-49 CHOL/HD-3.1 LDLcalc-93 ___ 06:00AM BLOOD TSH-1.4 ___ 06:00AM BLOOD CRP-0.5 ___ 12:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG *********** IMAGING DATA MRI Head w/o contrast ___ MRI BRAIN: There is evolution of previously seen infarctions in the left occipital lobe and left cerebellar hemisphere when compared with the prior study dated ___. There is no evidence of acute infarction or of hemorrhage. The ventricles are normal in size without mass effect or midline shift. The major visualized arterial vascular flow voids are preserved. The mucosal retention cysts within bilateral maxillary sinuses with mild mucosal thickening of bilateral ethmoid air cells. There is trace T2 hyperintensity within the left mastoid air cells. The orbits appear unremarkable. MRA BRAIN: The intracranial vertebral and bilateral internal carotid arteries and the major branches appear patent without stenosis, occlusion, or aneurysm. There is no evidence of dissection. MRA NECK: The previously seen dissections involving the V3 segment of the left vertebral artery and V1/V 2 segments of the right vertebral artery as seen on the prior CTAs dated ___ and ___ on the current study demonstrate no corresponding intrinsic T1 hyperintensity. There is expected enhancement of bilateral vertebral arteries without stenosis or occlusion. Constellation of findings suggest interval resolution of previously seen dissections. The bilateral common carotid arteries appear patent. There is no internal carotid artery stenosis by NASCET criteria. 1. No evidence of acute infarction or of hemorrhage. 2. Evolution of left cerebellar and left occipital lobe infarctions. 3. Interval resolution of previously seen bilateral vertebral artery dissections when compared with the prior CTAs dated ___ and ___, and corresponding to most recent outside CTA dated ___. Otherwise, unremarkable MRA neck. 4. Unremarkable MRA head without intracranial stenosis, occlusion, or aneurysm. 5. Mild paranasal sinus disease, as above. Brief Hospital Course: ___ year old woman with history of bilateral vertebral dissections c/b multiple CVAs in ___ and Asthma who presents from OSH due to concern for worsening vertebral dissection in setting of worsened headache and neck pain. Exam was initially notable residual RLE numbness as well as new R sided facial numbness (which subsequently improved, affecting only right forehead and gradually improving). Workup included repeat MRI/MRA which revealed no new strokes, and interval resolution of previously seen bilateral vertebral artery dissections when compared with the prior vessel imaging in ___. After discussion with the patient's outpatient neurologist Dr. ___ made to stop anticoagulation and replace with aspirin, given that vertebral dissections had resolved. Therefore heparin and warfarin was stopped. Patient's pain was well controlled with Tylenol 1g TID as well as flexeril for treatment of muscle spasm (noted tenderness and spasm of occipitalis and trapedius muscles to palpation). TRANSITIONAL ISSUES: - Follow up with Dr. ___, as scheduled - Continue aspirin 81mg daily. STOP lovenox and warfarin. - pain control with Tylenol and flexeril as needed for muscle spasm - Continue previously arranged outpatient ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 80 mg SC BID Start: Today - ___, First Dose: Next Routine Administration Time 2. Warfarin 10 mg PO DAILY16 3. Montelukast 10 mg PO DAILY 4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm, headache RX cyclobenzaprine 5 mg 5 tablet(s) by mouth TID PRN Disp #30 Tablet Refills:0 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea/vomiting and headache RX ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every 8 hours PRN Disp #20 Tablet Refills:0 5. Montelukast 10 mg PO DAILY 6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Disposition: Home Discharge Diagnosis: Cervical and occipital muscle spasm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ ___ were admitted to the hospital with worsening headache and neck pain. To look into your symptoms, we did imaging of the blood vessels in your head and neck, as well as your brain, with MRI. Fortunately, this did not reveal any evidence of new strokes. Also, your vertebral arteries (the arteries that had dissections) had improved and no longer have dissections. Given that ___ no longer have dissections, we spoke with your outpatient neurologist Dr. ___ agreed to STOP the blood thinners (Coumadin and lovenox/heparin) and replaced this with baby aspirin (81mg) daily. Please continue this moving forward. Now that this is done, ___ no longer need the MRI brain/ MRA brain/MRA neck scans that were scheduled for ___. Follow up with your outpatient Neurologist, Dr. ___, has been arranged. ___ may continue pain management with Flexeril and Tylenol as instructed. It was a pleasure taking care of ___. Sincerely, Your ___ Care Team Followup Instructions: ___
19830154-DS-12	19,830,154	28,392,028	DS	12	2179-05-29 00:00:00	2179-05-29 16:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: clindamycin Attending: ___ Chief Complaint: Neck pain Major Surgical or Invasive Procedure: n.a. History of Present Illness: This is a ___ year old woman with a significant stroke history notable for bilateral cerebellar infarcts (___) including left cerebellar infarct and left occipital infarct (___) secondary to bilateral vertebral artery dissection thought to be related to undiagnosed connective tissue, with genetic workup only revealing for SMAD3 (reviewed below). She presents today as ___ transfer out of concern for new right vertebral artery dissection. History obtained by patient and her sister at bedside. Per patient, she reports that she was in her usual state of health up until two weeks ago when she noticed bilateral neck pain that migrated from one side of her neck to the other. She initially thought she had tight neck muscles related to stress, as she has been undergoing several exacerbating stressors with her parents (she does not wish to go into the details on history today, but notes that she has had to stop talking to her parents in the interim to avoid the stress). Her pain persisted and she says perhaps subconsciously she was worried she was having a similar event as that which happened on ___ and ___, because both of these events were also precipitated by similar neck pain. As such she started to take 81 mg aspirin on a daily basis. She decided to give the symptoms time to see if they ___. Unfortunately, they persisted. This morning she woke up with progression of her neck pain to being completely vertiginous, with a sensation that the room was spinning even as she lay in bed. She tried to get up to vomit and noted difficulty making it to the toilet without stumbling. She then had to vomit for "close to an hour." After the vomiting, her boyfriend encouraged her to go to the hospital. As she was getting ready to get into his car, she suddenly developed blurry vision. Her boyfriend thought he noticed one of her eyes look funny, as if it were "lazy." She at this point noted that she just couldn't swallow. She was able to talk and to understand, but couldn't swallow her saliva. She got into her boyfriend's car and within 10 minutes, her blurry vision resolved and she could swallow again. She was taken to OSH where she was given ASA 81 mg. CTA head and neck was concerning for new right V4 dissection and she was transferred to ___ for further management. Regarding prior stroke history: - ___: bilateral cerebellar stroke from bilateral vertebral artery dissection - ___: left cerebellar, left occipital stroke from repeat dissection - maintained on warfarin and lovenox, lovenox stopped, maintained only on warfarin,, then warfarin discontinued ___ - was reportedly advised to continue ASA 81 mg and vitamin C Etiology of stroke thought to be related to undiagnosed connective tissue disorder. As per Dr. ___: " No inciting cause for the dissections has been found. The thoracic aortic aneurysm panel showed that she has a heterozygous mutation of uncertain significance in the ___ gene. This mutation has not previously been linked to any pathology. Of note, the SMAD3 gene encodes for important proteins that play a role in the TGF B pathway. Some SMAD3 mutations may lead to the ___ connective tissue disorder." The patient notes that she did not take aspirin every day until feeling her neck pain two weeks ago. No recent neck traumas, whip lash, head injuries. ROS: On neurological review of systems, the patient denies confusion, difficulties producing or comprehending speech, loss of vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies recent fever, chills, night sweats, or recent weight changes. Denies cough, shortness of breath, chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. Denies dysuria, or recent change in bowel or bladder habits. Denies arthralgias, myalgias, or rash. Past Medical History: Recent bilateral cerebellar infarctions with bilateral vertebral artery dissections as listed in HPI. Asthma H. pylori Patient does not a have a history of blood clots or connective tissue disorder that she is aware of Social History: ___ Family History: Patient denies a family history of stroke at a young age, blood clots, connective tissue disorders, or autoimmune disorders. Physical Exam: Admission Physical Exam: Vitals: T97.3, ___, RR18, 100RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, ___. Abdomen: Soft, ___. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI. Unilateral low amplitude ___ nystagmus on left lateral gaze. With fast eye movements, appears to have ocular flutter. With fast eye movements between objects, has saccadic intrusions of smooth pursuit. No skew deviation with cover/uncover. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to ___ bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with ___ testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 4+ 4+ 4 5- 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 1 1 1 1 1 R 1 1 1 1 1 Plantar response was with withdrawal bilaterally. -Coordination: No intention tremor. Normal ___ bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. ___, normal stride and arm swing. Discharge Physical Exam: VS: T 98.0 BP 118/80 HR 63 RR 18 SpO2 99% on Ra General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, ___. Abdomen: Soft, ___. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI. Unilateral low amplitude ___ nystagmus on left lateral gaze. No skew deviation with cover/uncover. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to ___ bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with ___ testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 1 1 1 1 1 R 1 1 1 1 1 Plantar response was with withdrawal bilaterally. -Coordination: No intention tremor. Normal ___ bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. ___, normal stride and arm swing. Pertinent Results: ___ 10:57AM BLOOD ___ ___ Plt ___ ___ 10:57AM BLOOD ___ ___ ___ 07:52AM BLOOD ___ ___ ___ 10:57AM BLOOD ___ ___ ___ 10:57AM BLOOD ___ ___ 10:57AM BLOOD ___ ___ 10:57AM BLOOD ___ ___ 07:52AM BLOOD ___ ___ 07:52AM BLOOD ___ ___ 07:52AM BLOOD ___ ___ 10:57AM BLOOD ___ ___ MR HEAD W/ CONTRAST; MRA BRAIN W/O CONTRAST 1. ___ late acute to early subacute infarct of the right cerebellar hemisphere and right central vermis. 2. Right vertebral artery dissection involving the segment ___ junction. No evidence of occlusion or aneurysm formation. 3. Evidence of active sinus disease as described above. Brief Hospital Course: Ms. ___ is a ___ female with a history of bilateral vertebral artery dissections resulting in bilateral cerebellar strokes who is admitted to the Neurology stroke service with dizziness, nausea and vision changes secondary to an acute ischemic stroke in the right cerebellar hemisphere and right central vermis. Her stroke was most likely secondary to right vertebral artery dissection seen on MRI. She was started on dual antiplatelet therapy of ASA 81 and Plavix. Her exam on admission was notable only for subtle nystagmus on left gaze, which was still present at time of discharge. Etiology is presumed connective tissue disorder. Her stroke risk factors include the following: 1) DM: A1c 5.1% 2) LDL 67 3) TSH 1.0 Patient Summary: She underwent a CTA which showed a possible dissection of the right ___ segment of the vertebral artery. MRI with fat saturation showed a ___ late acute to early subacute infarct of the right cerebellar hemisphere and right central vermis and right vertebral artery dissection involving the segment ___ junction. There was no evidence of occlusion or aneurysm formation. There was also active sinus disease inclusing mucosal thickening in the ethmoidal air cells, moderate amount of fluid in the right paranasal sinus, and mucosal thickening and fluid with near complete opacification in the left paranasal sinus. STROKE SERVICE CORE MEASURES DOCUMENTATION - in the Meds section: Ischemic Stroke/TIA DC Summary checklist - in the Exam section: ICH DC Summary checklist - in the Followup section: DC Worksheet template (that counts for Stroke Education) Relevent Meds, ___ PMHx: AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed â () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 67) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [x] ___ less than 70 mg/dL] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) ___ - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [x] ___ less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyclobenzaprine 5 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 2. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute ischemic stroke due to right vertebral artery dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of nausea, dizziness, vision changes and difficulty swallowing resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - Presumed connective tissue disorder We are changing your medications as follows: - Begin taking Plavix 75mg daily for 3 weeks - Continue taking Aspirin 81mg daily indefinitely Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
19830436-DS-5	19,830,436	24,620,989	DS	5	2160-08-02 00:00:00	2160-08-08 10:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Left-sided weakness and numbness s/p MVC Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male no significant PMH who presents to the ED as transfer from OSH for concerned of lue weakness. He was a restrained driver in a motor vehicle collision. His car was t-bone, he was restrained. The car was going approximately 20 mph. He did any head strike no loc. CT head/neck were performed and it was negative. His main complain is left upper weakness/numbness in his fourth and fifth digit and lateral aspect of his left is also numb. He denies any fever, chills, no urinary incontinence, no bowel incontinence. Past Medical History: Denies Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Temp: 98.3 HR: 80 BP: 118/84 Resp: 18 O(2)Sat: 98 Normal Constitutional: No acute distress HEENT: pupils 3x2 bilaterally, Normocephalic, atraumatic Oropharynx within normal limits, in c-collar, diffuse C-spine tenderness Chest: chest wall nontender, bilateral breath sounds Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender, Nondistended Extr/Back: Pelvis is stable, BLE and BUE nontender with no evidence of trauma. No midline tenderness Skin: Warm and dry Neuro: Speech fluent, ___ LUE strength, ___ LLE strength Psych: Normal mentation, Normal mood ___: No petechiae Discharge Physical Exam: VS: T: 97.9, BP: 129/63, HR: 80, RR: 18, O2: 100% RA GENERAL: A+Ox3, NAD Neuro: ___ LUE and LLE strength CV: RRR, no m/r/g PULM: CTA b/l EXTREMITIES: Warm, well-perfused b/l, no edema. BLE and BUE nontender with no evidence of trauma. Pertinent Results: IMAGING: ___: CXR: No acute findings on this limited exam ___: CTA Head & Neck: Unremarkable head and neck CTA. No evidence of vascular injury. ___: MRI Cervical Spine: No significant abnormalities on MRI of cervical spine. No evidence of bony or ligamentous injury. Brief Hospital Course: Mr. ___ is a ___ year-old who was transferred from ___ to the ___ ED with left-sided weakness s/p MVC. At the OSH, he underwent a Head and Neck CT which were normal, however, he developed left-sided weakness while there and he was transferred to ___ for further Trauma workup. On HD1, the patient had a CXR, CTA Head & Neck which did not demonstrate any injury. He also had a MRI of the cervical spine which did not reveal any injury. The patient was admitted to the Acute Care Surgery service and transferred to the surgical floor for further observation. The Neurology and Orthopaedic services were consulted and no intervention was necessary. The patient reported improving symptoms. The remainder of the ___ hospital course is discussed by systems below: The patient was alert and oriented throughout hospitalization; pain was well-controlled. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. The patient remained stable from a pulmonary standpoint. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient tolerated a regular diet. Patient's intake and output were closely monitored. The patient's fever curves were closely watched for signs of infection, of which there were none. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: MVC without any traumatic injuries Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after a motor vehicle collision with concern of weakness and decreased sensation of your left side. You had an MRI of your neck, a chest x-ray and a CTA, and no injuries were found. You were evaluated by the Neurology and Orthopaedic Surgery services and no further work-up is necessary. You are now medically cleared to be discharged home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
19830515-DS-21	19,830,515	24,157,504	DS	21	2144-01-27 00:00:00	2144-01-27 18:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Anemia Major Surgical or Invasive Procedure: esophagoduodenoscopy with feeding tube placement, then removal History of Present Illness: Mr. ___ is a ___ y/o male with a history of cirrhosis ___ HBV diagnosed on ___ who presents with a Hct of 22.9. Patient receives large volume paracentesis weekly and was noted to have a bloody tap on ___. He was also noted to be weak and unsteady on his feet according to ED referral. Labs were performed which revealed a Hct of 22.9 down from 24.7 on ___. He denied having any symptoms. He specifically denied having any lightheadedness, chest pain, shortness of breath or abdominal pain. He denied any hematochezia, hematuria or epistaxis. He did have a fall approximately one week ago and sustained multiple ecchymoses and skin abrasions, unknown head strike but denied LOC. He did not have a medical evaluation after the fall. There is concern that patient has been having difficulty taking care of himself at home and is declining. . He also notes that his Dobhoff "broke" early this week. He is not sure why this happenned but notes that it just fell apart. He states that there was no plan to place another dobhoff. According to patient he is able to eat but feeding tube was placed because he was significantly malnourished. . In the ED, initial VS: 96.9 100 82/38 16 100% RA. He was given a tetanus booster and given a dose of ceftriaxone. He had a diagnostic tap which showed 500 WBC and 65% polys. His blood pressure improved without intervention. He had a head CT which was negative for an acute intracranial process. . On the floor, he noted that he was doing well and denied any discomfort. He notes that he feels as if things are going well at home and denied that he required any further assistance. Past Medical History: # Cirrhosis with portal ___ # HBeAG-positive HBV - Diagnosed ___ # Pancreatic cyst - S/p EUS with FNA pancreatic head cyst on ___ with negative cytology but Red Path testing suggestive of mucinous cyst. # History of at least moderate alcohol # Hypertension # Hyperlipidemia #History of rectal CA (around ___- s/p resection diagnosed approximately ___ years ago. Managed through GI at ___ ___. He states he undergoes ___ year colonoscopy. Per outside notes, his last colonoscopy was ___ with three polyps (one of which was an adenoma.) # History of SCC/BCC # Elevated CA ___ - 85 (___) # ECHO ___ notes borderline pulmonary artery systolic hypertension # Cholelithiasis # OSH Chest CT ___ with features of bronchiectasis Social History: ___ Family History: Mother died of renal failure (unknown why). Paternal Aunt with pancreatic cancer, and Maternal grandmother with pancreatic cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp F 97.8, BP 97/52, HR 89, 95 O2-sat % RA GENERAL - cachetic appearing but comfortable and in NAD, appropriate HEENT - EOMI, sclerae anicteric, MMM NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - ___ pitting edema, no cyanosis or clubbing SKIN - multiple ecchymoses noted throughout shoulder and face NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: Admission Labs: ___ 08:10PM BLOOD WBC-12.4* RBC-2.00* Hgb-7.6* Hct-22.4* MCV-112* MCH-37.9* MCHC-34.0 RDW-16.4* Plt ___ ___ 08:10PM BLOOD Neuts-83.3* Lymphs-9.6* Monos-6.2 Eos-0.6 Baso-0.3 ___ 12:45PM BLOOD ___ ___ 08:10PM BLOOD Glucose-158* UreaN-104* Creat-2.1* Na-129* K-5.2* Cl-99 HCO3-18* AnGap-17 ___ 08:10PM BLOOD ALT-26 AST-39 AlkPhos-95 TotBili-3.2* ___ 08:10PM BLOOD Lipase-141* ___ 03:35PM BLOOD Albumin-2.8* ___ 08:10PM BLOOD Calcium-8.7 Phos-5.7# Mg-2.6 ___ 08:19PM BLOOD Glucose-148 Na-129* K-5.1 Cl-102 calHCO3-19* ___ 08:19PM BLOOD Hgb-8.0* calcHCT-24 ___ 10:50PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 10:50PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 10:50PM URINE CastHy-12* Ascites fluid: ___ 01:55PM ASCITES WBC-500* ___ Polys-65* Lymphs-16* Monos-15* Eos-1* Macroph-3* ___ 12:48PM ASCITES WBC-1000* ___ Polys-50* Lymphs-4* Monos-12* Mesothe-2* Macroph-32* ___ 01:30PM ASCITES WBC-1250* HCT,fl-<2.0 Polys-45* Lymphs-25* Monos-10* Mesothe-1* Macroph-19* ___ 01:30PM ASCITES Glucose-138 LD(LDH)-159 Urine: ___ 06:35PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 06:35PM URINE Hours-RANDOM Na-<10 K-33 Cl-<10 ___ 06:35PM URINE Osmolal-429 ___ 01:40PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 01:40PM URINE Hours-RANDOM UreaN-860 Creat-51 Na-LESS THAN K-42 Cl-LESS THAN ___ 01:40PM URINE Osmolal-461 Coagulability: ___ 06:20AM BLOOD ___ 06:20AM BLOOD Fibrino-85* ___ 11:55PM BLOOD Fibrino-71* Discharge Labs: Microbiology: ___ PERITONEAL FLUID GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ URINE CULTURE (Final ___: <10,000 organisms/ml. ___ CULTURE - NO GROWTH ___ HBV Viral Load (Final ___: 175,000 IU/mL ___ CULTURE - NO GROWTH ___ PERITONEAL FLUID GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ CULTURE - PENDING ___ CULTURE - PENDING ___ 1:40 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R ___ 1:30 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ CULTURE - PENDING ___ CULTURE - PENDING ___ MRSA SCREEN (Final ___: No MRSA isolated . Imaging: U/S Para (___): IMPRESSION: Technically successful diagnostic and therapeutic paracentesis Preliminary Report yielding 7.5 liters of serosanguineous ascites. Labs are pending. . Head CT (___): IMPRESSION: No acute intracranial process. . CXR (___): No part of the Dobbhoff tube is visible on the current image. There is no safe evidence of rib fractures or other traumatic changes. Normal size of the cardiac silhouette. No pleural effusions. No pneumothorax. Normal hilar and mediastinal contours. . EGD (___): Impression: - Food residue in the lower third of the esophagus - Food in the stomach body and fundus - Portal hypertensive gastropathy - Mild duodenitis - A ___ Fr ___ feeding tube was placed successfully using standard endoscopic technique. A ___ Fr bridle was placed successfully using starndard technique. - Otherwise normal EGD to jejunum Recommendations: - Portal hypertensive gastropathy may be the source of his anemia. - Start PPI 40mg BID and carafate slurry 1gram QID. - Tubefeeds per Nutrition recommendations. - Return to hospital floor. . ___ (___): IMPRESSION: 1. Bilateral short segment, nonocclusive deep venous thrombosis in the common femoral veins. 2. Nonvisualization of the popliteal veins bilaterally secondary to overlying bandages. The superficial femoral and calf veins are patent bilaterally. CT Abdomen and Pelvis (___): 1. No perforation. 2. Moderate amount of ascites with the dependent pelvic component being more hypodense, suggestive of blood products, possibly from prior paracentesis. 3. New compression fracture at T12. 4. Bibasilar patchy consolidations may reflect infection or aspiration in the right clinical setting. 5. Unchanged pancreatic cyst and cholelithiasis. Brief Hospital Course: Mr. ___ was admitted with worsening liver function, and his hospital course was complicated. He had a poor prognosis, and multiple medical co-morbidities. On ___, while the patient was in the MICU, a family meeting was held with the patient, his partner, hospice, and Social Work. During this discussion it was decided to focus on comfort measures only, given his worsening clinical status and unlikely recovery. Following this discussion, antibiotics and most other medications were discontinued. Tube feeding was stopped in preference for comfort feeding. Lab draws were stopped. Morphine was used for pain. Ativan for anxiety. After many ungoing discussions between the patient, his partner and proxy, and all members of the medical team, including nursing, physicians, palliative care and hospice, social work, and case management, the patient was discharged to ___ with the goal of medical care to focus on comfort. . The patient's prognosis is very poor, and he was discharged as DNR/DNI with focus on comfort measures only. Medically, there was no further indication to do anything except focus on measures to keep Mr. ___ comfortable. If he returns to the emergency room, would strongly consider a discussion with the patient and his proxy as well as an ethics consult before initiating aggressive measures. Medications on Admission: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QTHUR (every ___. 3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosource 1.5 Cal Liquid Sig: ___ (65) cc/hr PO once a day: continuous. Flush with 30cc free water q6 hrs. . 6. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Eight Hundred (800) mg PO once a day. Discharge Medications: 1. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for Dry skin. 2. lorazepam 1 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for anxiety. 3. morphine 10 mg/5 mL Solution Sig: ___ mg PO Q2H as needed for pain. 4. sodium chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal QID (4 times a day) as needed for nasal dryness. Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: End stage liver disease Cirrhosis Hepatitis B Anemia Deep vein thrombosis Hepatorenal syndrome Spontaneous bacterial peritonitis Urinary tract infection Hepatic encephalopathy Sepsis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___, You were admitted to the hospital with worsening liver failure. After many discussion with you, ___, and all members of the medical team, the decision was made to focus foremost on your comfort. As such, you are being discharged to a facility with hospice, with the goal of your care to be to make you as comfortable as possible. . From all of us here at ___, it was a pleasure taking care of you, and getting to know you better. Please make the following changes to your medications: 1. Start lorazepam as needed for anxiety and shortness of breath. 2. Start morphine as needed for pain and shortness of breath. 3. Use vaseline as needed for dry skin. Followup Instructions: ___
19830631-DS-10	19,830,631	28,671,373	DS	10	2147-06-07 00:00:00	2147-06-07 19:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: FTT/SI Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ female with recently diagnosed early onset dementia with behavioral disturbance who presents with a family friend concern for depression, suicidal ideation, aggressive behavior towards family members and failure to thrive. Of note, pt had recent hospitalization from ___ this year for suicidal ideation and AMS. Per psych note, family friend states that for about the past month, patient has had ongoing withdrawn, depressed mood. She frequently says that she wants to kill herself or she wants to die. On prior admission, she was noted to hit herself on legs and body. She cries frequently. She has been intermittently agitated and aggressive towards family members. ___ have persisted and become worse over the past ___ weeks. Of note, she has no prior psych history prior to the last admission, hospitalizations or suicide attempts. She has a history of development delay with special education up to ___ grade. Her family history includes depression, Alzheimer's dementia (multiple relatives, early-onset), bipolar and anxiety disorders. Patient has been very withdrawn during interviews with very limited answers to questions. She denies SI, HI, AVH. She is crying but unable to describe how she is feeling. Per OMR, patient was seen by cognitive neurology yesterday. They suspected some comorbid depression and started her on a low-dose of escitalopram. In the ED: Initial vital signs were notable for: T97.9, HR96, 120/76, RR16, 100%RA Exam notable for: no findings noted Labs were notable for: WBC/BMP WNL Utox Neg UA negative Studies performed include: None Patient was given: Zyprexa 5mg for agitation donepezil 5 mg Escitalopram 5 mg Consults: Psychiatry, SW Vitals on transfer: T97.7, 119/83, 63, 100% RA Upon arrival to the floor, pt was stable. She was complaining of pain on her left chest that she did not answer when it started or the quality of it. She had short appropriate answers to some questions and was unintelligible in other responses. She denied nausea, fevers, chills. Nursing report said she was directable when she wandered out of her room and was not combative on transfer. Complete ROS obtained and is otherwise negative. Past Medical History: Early-onset Alzheimer's Dementia Social History: ___ Family History: Taken from Psych admission note and Neuro Cognitive clinic note: Father reportedly died of Alzheimer's dementia in his early ___ (possibly had onset in his ___ though unclear). Mother reportedly had a series of strokes in her ___. A number of brothers and sisters have also had dementia with some early-onset disease, as early as ___. Per collateral, the patient's youngest sister was hospitalized in ___ for "depression, bipolar, anxiety" possibly with some component of psychosis, presented at 41. Physical Exam: ADMISSION PHYSICAL EXAM =========================== VITALS: T97.7, 119/83, 63, 100% RA GENERAL: ___ woman who looks older than stated age and with sad, tearful affect. Hand over her left chest. Alert and minimally interactive. In mild acute distress. HEENT: NCAT. EOMI. Sclera anicteric and without injection. MMM. NECK: No gross abnormalities. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. Minimally tender to palpation on L chest. ABDOMEN: Normal bowels sounds, non distended, tender to deep palpation in upper abdominal quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: Normal sensation. AOx name only. DISCHARGE PHYSICAL EXAM =========================== 24 HR Data (last updated ___ @ 1546) Temp: 98.0 (Tm 98.3), BP: 100/63 (100-117/63-68), HR: 82 (80-90), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: Ra GENERAL: ___ woman who looks older than stated age. Happy-appearing. HEENT: NCAT. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, nontender. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AAOx1 (herself). Moves extremities spontaneously. PSYCH: no waxy flexibility Pertinent Results: ADMISSION LABS ======================= ___ 11:45AM BLOOD WBC-5.9 RBC-4.50 Hgb-13.0 Hct-40.3 MCV-90 MCH-28.9 MCHC-32.3 RDW-12.9 RDWSD-42.0 Plt ___ ___ 11:45AM BLOOD Neuts-73.8* Lymphs-17.9* Monos-6.6 Eos-0.7* Baso-0.5 Im ___ AbsNeut-4.33 AbsLymp-1.05* AbsMono-0.39 AbsEos-0.04 AbsBaso-0.03 ___ 11:45AM BLOOD Glucose-93 UreaN-15 Creat-0.7 Na-142 K-4.2 Cl-101 HCO3-29 AnGap-12 ___ 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG RELEVANT LABS ======================= ___ 12:39AM BLOOD WBC-4.7 RBC-4.15 Hgb-12.3 Hct-36.5 MCV-88 MCH-29.6 MCHC-33.7 RDW-12.9 RDWSD-41.1 Plt ___ ___ 12:39AM BLOOD Glucose-103* UreaN-12 Creat-0.6 Na-142 K-3.7 Cl-103 HCO3-28 AnGap-11 ___ 12:39AM BLOOD ALT-7 AST-11 AlkPhos-63 TotBili-1.1 ___ 12:39AM BLOOD Lipase-15 ___ 04:35AM BLOOD cTropnT-<0.01 ___ 12:39AM BLOOD cTropnT-<0.01 ___ 12:39AM BLOOD Calcium-9.8 Phos-4.1 Mg-1.9 RELEVANT IMAGING ======================= ___ XR ABDOMEN PORTABLE 1. Moderate stool burden without signs of obstruction. 2. No gross pneumoperitoneum. Of note, detection of free air is limited on a supine only assessment. Consider obtaining an additional abdominal radiograph with left lateral decubitus views if the clinical concern for free intraperitoneal air persists. ___ CXR AP Heart size is normal. Mediastinum is normal. Lungs are clear. There is no pleural effusion. There is no pneumothorax. Brief Hospital Course: Please make sure that you follow up with your ___ psychiatrist, Dr. ___ at ___ Primary Care Follow Up: Name: ___ When: ___ at 9:45am Location: THE ___ Address: ___, ___ Phone: ___ Department: COGNITIVE NEUROLOGY UNIT When: PENDING With: ___, M.D. ___ Building: ___ Building ___) ___ Floor Campus: ___ Best Parking: ___ You need to be seen in Cognitive Neurology by Dr. ___ as part of your hospital follow up. That office is working on an appointment and will call you with the details. If you do not hear in 2 business days, please call the number listed above. Department: COGNITIVE NEUROLOGY UNIT When: ___ at 10:30 AM With: ___ Building: ___ Campus: ___ Best Parking: ___ Pending Results at Discharge: Currently no pending results Key Information for Outpatient Providers: SUMMARY ================ ___ with early-onset Alzheimer's dementia and rapid progressive functional decline who was brought to the hospital with suicidal ideation, depression, aggressive behavior and failure to thrive. Initially, due to impulsivity, the patient was placed on ___ and 1:1 sitter, but the 1:1 sitter was discontinued the day after presentation after her agitation had resolved and she no longer expressed desire or intent to harm herself. ___ was discontinued once she consistently denied any thought of harming self. She was followed closely by psychiatry, and psychiatric medication regimen was titrated such that her behavior was better controlled by the time of discharge. ACUTE ISSUES ================ #Early-Onset Alzheimer's Disease #Suicidal ideation The patient presented with suicidal ideation, depression, aggressive behavior and failure to thrive at home. She was also experiencing visual and auditory hallucinations, had been combative with family members, and had attempted to harm herself. She additionally had rapidly deteriorating functional status, unable to complete ADLs unassisted. Initially, she was placed on ___ along with a 1:1 sitter. Infectious and metabolic workup were negative. On the first day after hospitalization, her agitation and aggressive behavior had resolved, and the 1:1 sitter was discontinued. Later in this hospitalization, her ___ was lifted after she consistently denied any thought of harming herself. She was started and uptitrated on Seroquel, with significant improved control of her agitation and improvement in ability to perform ADLs. Her hallucinations also resolved after starting on Seroquel, which was thought to partially contribute to her improved ability to perform ADLs. Additionally, her home escitalopram was also increased. Her baseline mental status at home is alert and oriented to person only, with intermittent mumbling of words that are sometimes nonsensical, and this condition continued this admission. By discharge, her behavior was generally well-controlled, though she had frequently tearful affect, and when agitated she could be easily directed using non-pharmacologic means. #Healthcare proxy Prior to this hospitalization, the patient did not have a documented healthcare proxy. Over 4 consecutive days, multiple members of the care team asked the patient regarding her preferences for a healthcare proxy. Each time, the patient named her sister and primary caretaker, ___ (goes by ___, phone: ___, both when ___ was and was not next to the patient. Given the consistency of her answer, it was felt that the patient had capacity to name ___ HCP, and ___ became her HCP. An attempt was made to search for an inpatient (ex. ___ psych) facility, but no beds were available to this patient. Her insurance ultimately did not qualify her for home services. In discussion with HCP, it was agreed that patient would be discharge to home with attendance to an adult day care program to start promptly after discharge. HCP was in agreement with this plan. #CODE: Full (presumed) #CONTACT: Primary- ___ (sister), ___. Will need ___ interpreter. Alternative- ___ ___ (brother-in-law), ___ TRANSITIONAL ISSUES [] PSYCHIATRIC MEDICATIONS: The patient was discharged on quetiapine 12.5mg QAM and 25mg QHS, as well as escitalopram 10mg QD. Consider uptitration of these medications prn. [] PSYCHIATRY FOLLOW-UP: The patient was referred to psychiatrist Dr. ___ but could not make her first appointment. Please make sure patient has follow-up with psychiatry as an outpatient. [] APPETITE STIMULANT: The patient had poor PO at home and during this admission. If within goals of care, could consider a pharmacologic appetite stimulant. [] INSURANCE: HCP is in the process of applying/changing the patient's insurance; once this is accomplished, please arrange pt for additional home services such as with psych ___. [] SERVICES: Please investigate if patient qualifies for any additional services through ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Donepezil 5 mg PO QAM 2. Escitalopram Oxalate 5 mg PO QAM Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Polyethylene Glycol 17 g PO DAILY 4. QUEtiapine Fumarate 25 mg PO QHS 5. QUEtiapine Fumarate 12.5 mg PO QAM 6. Senna 8.6 mg PO BID 7. Escitalopram Oxalate 10 mg PO QAM 8. Donepezil 5 mg PO QAM Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES #Early-Onset Alzheimer's Disease #Suicidal ideation #Healthcare proxy Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dears ___, It was a pleasure caring for you at ___ ___. Why you were in the hospital: - Your family was concerned that you were more agitated and that you expressed thoughts of harming yourself. What we did while you were here: - We checked you for infections that could be causing your confusion and agitation, but we did not find any evidence of this. - The psychiatry team started you on some medications that would help you stay calm. What to do when you go home: -Take all your medications as prescribed and attend all your doctor's appointments. We wish you all the best, Your ___ Care Team Followup Instructions: ___
19830798-DS-21	19,830,798	27,449,326	DS	21	2169-08-23 00:00:00	2169-08-23 20:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: abdominal pain, hypotension Major Surgical or Invasive Procedure: Incision and debridement of left above-the-knee amputation. Approximate size is 30 cm by 20cm or 600 square cm. application vac sponge Excisional debridement and assessment of medial and posterior muscles of the left above-knee amputation stump and placement of vacuum dressing. Left hip disarticulation and complex primary closure Resection of right limb infected fem-fem bypass graft, and patch closure of right common femoral artery using a branch of greater saphenous vein. History of Present Illness: ___ with HTN, DM, PVD and recent Lt AKA c/b recurrent wound ___ transferred to ___ for further surgical management. Pt initially presented septic and with abdominal pain ___ diverticulitis. Remaining HPI take from ID note ___: "He was admitted at ___ from ___ after presenting with acute LLE pain, found to have LLE ischemia and compartment syndrome treated with fasciotomy. His course was c/b DKA, rhabdo, and acute kidney injury. Patient ultimately underwent LLE AKA on ___ and discharged to Rehab on ___. At rehab, he was noticed to have frank purulence from AKA site; transferred to ___ for further management. He underwent multiple debridements at ___, however was eventually transferred here after MRI showed osteomyelitis of LLE AKA site. Of note, cultures there showed yeast and treated with fluconazole. He was transferred here and underwent several debridements prior to performing left hip disarticulation on ___. He underwent further removal of arterial graft on ___. Intra op culture data from the left hip disarticulation showed ___, and bacillus spp. He was treated with long course of dapto/cefepime/micafungin, however finished on ___ (72 hours post surgery). He was discharged to rehab, however returned with fever, hypotension, and abdominal pain. CT a/p showed sigmoid diverticulitis, however also showed locules of gas and fat stranding in left acetabular cavity. He was admitted to SICU and started on vanc/pip-tazo for diverticulitis coverage. C diff returned positive on ___ and started on oral vancomycin. Due to worsening mental status and concern for source control, patient was taken to OR for I&D and washout of left acetabular cavity on ___ murky fluid was found intra op and sent for culture." Past Medical History: PAST MEDICAL / SURGICAL HISTORY: HTN DM2 PAD R to L fem-fem bypass w/PTFE and LLE thrombectomy with L calf 4 compartment fasciotomy on ___ L AKA ___ L stump debridement ___ Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Afebrile, HR 110-120s, BP ___ - SBP 120s) on levophed 0.09 mcg/kg/min, RR ___, SaO2 95% 2L NC. GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Mild bibasilar crackles, No W/R/R ABD: Soft, nondistended, tender in LLQ just slightly to left of midline with focal fullness, no rebound or guarding or signs of peritonitis. Ext: Left hip disarticulated with stapled wound - fullness without focal induration, slight erythema, no drainage; RLE warm well perfused. ================== Discharge PEX: 98.2 PO 148 / 87 L Lying 88 18 97 Ra Gen: AOx3, NAD HEENT: no scleral icterus, MMM CV: RRR, no r/m/g Pulm: CTAB Abd: NABS, non-tender, non-distended with JP drain removed from abdomen Ext:Left hip disarticulated stump with staples in place and c/d/I dressing at surgical site, Right ext with 2+ pulses Neuro: AO3, moving extremities equally Pertinent Results: Admission Labs: ___ 10:00PM BLOOD WBC-14.3* RBC-3.30* Hgb-9.5* Hct-30.3* MCV-92 MCH-28.8 MCHC-31.4* RDW-16.7* RDWSD-56.7* Plt ___ ___ 03:38PM BLOOD Neuts-82.6* Lymphs-6.5* Monos-8.7 Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.72* AbsLymp-0.93* AbsMono-1.24* AbsEos-0.01* AbsBaso-0.04 ___ 03:38PM BLOOD Glucose-232* UreaN-29* Creat-2.3# Na-131 K-8.1* Cl-97 HCO3-17* AnGap-25* ___ 03:32AM BLOOD Calcium-8.4 Phos-5.4* Mg-1.2* Discharge labs: ___ 04:23AM BLOOD WBC-8.3 RBC-3.04* Hgb-8.8* Hct-28.0* MCV-92 MCH-28.9 MCHC-31.4* RDW-16.7* RDWSD-56.0* Plt ___ ___ 04:46AM BLOOD Neuts-60 Bands-0 ___ Monos-4* Eos-1 Baso-0 Atyps-1* Metas-2* Myelos-3* AbsNeut-5.16 AbsLymp-2.58 AbsMono-0.34 AbsEos-0.09 AbsBaso-0.00* ___ 04:23AM BLOOD Glucose-112* UreaN-11 Creat-1.1 Na-139 K-4.4 Cl-101 HCO3-24 AnGap-14 ___ 08:19AM BLOOD ALT-5 AST-13 AlkPhos-99 TotBili-0.2 ___ 04:23AM BLOOD Phos-3.6 Mg-2.3 ___ 08:19AM BLOOD %HbA1c-5.6 eAG-114 ___ 08:19AM BLOOD TSH-0.50 ___ 08:19AM BLOOD CRP->72.66* Imaging: KUB ___ Nonobstructive bowel gas pattern. Colonic wall thickening, likely in keeping with the provided history of colitis. CT chest ___. Uncomplicated sigmoid diverticulitis. 2. Apparent locules of gas with extensive fat stranding in the left acetabular cavity extending anteriorly toward the cutaneous staple line. While these changes can be seen in the postoperative period, recommend correlation with surgical date as this finding would be abnormal more than 1 week postoperative and raise the possibility of infection. 3. Unchanged 2.1 cm left adrenal nodule, statistically likely an adenoma. Recommend correlation with biochemical markers and consider ___ year follow-up dedicated adrenal protocol CT or MRI for further evaluation. 4. Severe calcified coronary atherosclerosis. 5. The bladder is decompressed by Foley catheter, but the bladder wall appears somewhat thickened. Correlation with urinalysis is recommended to exclude infection. Micro: ENTEROCOCCUS SP.. RARE GROWTH. Daptomycin SUSCEPTIBILITY REQUESTED BY ___ ___ ___. Daptomycin MIC 3 MCG/ML. Daptomycin test result performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>___ R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: Surgical course: Mr. ___ is a ___ year old man admitted from rehab facility with abdominal pain, fever, and hypotension. Recent history notable for left hip disarticulation ___ subsequent to complications from LLE ischemia and fem-fem PTFE bypass ___ followed by left AKA and wound ischemia - CTA showed perfusion up to left internal iliac artery. He initially presented on ___ and complained of no left hip discomfort. The patient was hypotensive, tachycardic, and had abdominal tenderness. CT of abdomen showed diverticulitis and the patient was started on antibioitics, pressors for hypotension, a central line was placed and he was admitted to the ICU for ongoing close monitoring and intervention. While in the ICU, a bedside echo was obtained, which was reassuring for cardiac function. He was also on pressors at this time. A radial A-line was placed, and he was evaluated by orthopedic surgery who did not suspect a surgical site infection. They recommended a vascular surgery consult as they believed the free air was like from removal of fem-fem graft. On ___ he was found to be C Diff positive, and oral vancomycin was started in addition to the intravenous antibiotics that he was on at that time. Zosyn was discontinued. A-line was non-functional, and removed. He was started on a diet of ice chips. He continued to require pressors. On ___ he did not have any ICU needs and was transferred to the floor in good condition. The patient remained alert but intermittently agitated. ___ resolved leukocytosis ___ 5mg IV haloperidol for severe agitation; restrictions in place ___ OR for hip washout, cont PO vanc, d/c abx, adv reg diet ___ persistent agitation, improved from earlier in the week ___ persistent agitation, improved pain ___: Excisional debridement more than 20 square cm in the left hip excisional including the skin and subcutaneous tissues. Complex closure of surgical wound measuring 14 cm in length. Medicine transfer ___: Patient was transferred with concern for delirium. Course on the medical service as follows: #Delirium- On initial exam he was found to be alert and oriented x3 without evidence of delirum. Electrolytes and testing for TSH and B12 wnl. Delirium likely in the setting of prolonged hospitalization as infection. He had no further episodes after transfer to medicine and was therefore transferred to rehab on ___. #Surgical site infection: Most recent cultures with ___ (sensitive to daptomycin) and yeast, likely C. Glabrata given prevouious cutltures. He was started on IV Daptomycin as well as Micafungin. Plan for 4 weeks of IV antibiotics with ID follow up and monitoring labs. #C.diff colitis: Continued on PO vanc with improvement of diarrhea. Will need to continue PO vanc until at least the completion of above antibiotic course. Further course of vanco to be determined by ID at follow up. # diverticulitis: He was not on antibiotics at the time of transfer to the medicine service and it appears that he did not receive a complete course of abx while on the surgical service. Given he was asymptomatic and stable while on the medicine service, no further antibiotics were given. #Urinary retention: Following removal of foley catheter, patient failed a voiding trial with PVR of 750cc requiring straight cath. He continued to have difficulty urinating x2 with PVR of 650cc. Another foley was placed. CT scan without evidence of enlarged prostate so patient will not benefit from Tamsulosin. Retention likely in the setting of post operative opioid use. Consider Urology follow up outpatient if he continues to fail voiding trials. #DM- Patient denies history of DM prior to hospitalization. He was started on sliding scale but did not require any insulin while on medicine floor. His HgbA1C was 5.6% (in the setting of transfusion in the past month). Given his low HgbA1c and relatively normal fasting glucose (100-130), he likely does not have diabetes. HgbA1c will need to be rechecked in a few months to ensure that the transfusion did not give a falsely low result. TRANSITIONAL ISSUES: ==================== - Complete course of Daptomycin 550 IVq24 (D1 = ___ for ___, and Micafungin 100 mg IV Q24H through ___ (tentative) - will be followed in outpatient ___ clinic - Weekly labs as follows for IV medications: ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK MICAFUNGIN: WEEKLY: LFTs - Follow up with Orthopedics surgery in 2 weeks following discharge for evaluation and removal of staples on the left surgical site - Found to have a stable 2.1 cm left adrenal nodule on CT abdomen, statistically likely an adenoma. Recommend correlation with biochemical markers and consider ___ year follow-up dedicated adrenal protocol CT or MRI for further evaluation. - Discharged on foley for urinary retention. Consider Urology follow up if he fails additional voiding trails - Obtain repeat HgbA1c in ___ months as we suspect inpatient value is confounded by transfusions MEDICATION CHANGES - Holding HCTZ 25mg and Irbesartan 300mg daily due to normotension off medications post op. Please restart as needed. - Decreased metoprolol tartrate from 100mg to 50mg BID for normotension at this dose post operatively. Please uptitrate as needed. Pt is stable for discharge. >30 min spent on dc related activities. Medications on Admission: -fluconazole 400mg daily -Zosyn 2.25g q6h -vancomycin 1.5g daily -metoprolol tartrate 37.5 q6h -irbesartan 300mg PO -clobetasol 0.05% ointment -fluocinonide-emollient 0.05% cream -gabapentin 300mg daily -lidocaine 5% patch -Ativan 0.25mg IV q6h prn -nystatin powder -nystatin ointment -oxycodone -pantoprazole 40mg daily -trazodone 100mg daily -triamcinolone 0.1% ointment daily -simvastatin 40mg daily -allopurinol ___ daily Discharge Medications: 1. Acetaminophen (Liquid) 975 mg PO Q8H 2. Bisacodyl 10 mg PR QHS:PRN Constipation 3. Daptomycin 550 mg IV Q24H Start Date: ___ Projected End Date: ___ (tentative) 4. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 5. Heparin 5000 UNIT SC BID 6. Micafungin 100 mg IV Q24H Start Date: ___ Projected End Date: ___ (tentative) 7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #10 Tablet Refills:*0 8. Pantoprazole 40 mg PO Q24H 9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 10. Vancomycin Oral Liquid ___ mg PO Q6H continue at least through ___ and possible 14 days afterward - TBD by infectious disease 11. Metoprolol Tartrate 50 mg PO BID 12. Allopurinol ___ mg PO DAILY 13. Dextroamphetamine 5 mg PO QID 14. Hydrocortisone Cream 2.5% 1 Appl TP DAILY PRN flaky skin around eyes and ears 15. LORazepam 1 mg PO QHS:PRN Insomnia avoid giving at same time as pain medication 16. Simvastatin 40 mg PO QPM 17. TraZODone 50 mg PO QHS:PRN insomnia 18. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until your doctor tells you to restart 19. HELD- irbesartan 300 mg oral DAILY This medication was held. Do not restart irbesartan until your doctor tells you to restart Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Left surgical site infection s/p L hip disarticulation Secondary diagnosis: C.diff colitis Delirium Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to the Acute Care Surgery Service on ___ with abdominal pain and signs of infection. You had a CT scan that was concerning for an infection in your colon. You had a stool sample sent that was positive for an infection called clostridium difficile. You were given the appropriate antibiotic treatment for this. You were also found to have a small fluid collection in your left hip incision. You were taken to the operating room with the orthopedic surgery team and had the hip washed out and a wound vac applied. The wound vac was removed on ___, and the incision was closed. Your drain was removed on ___ right before discharge. While on the medicine floor, we continued your antibiotics for treatment of the stool with clostridium difficile and the infection of your leg. INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Out of bed as tolerated, please be cautious of L hip incision. - Weight bearing as tolerated for right lower extremity. - No extremity for weightbearing of left lower extremity. MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take subcutaneous heparin 5000u twice /day WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. Please make an appointment with urology to follow up with urinary retention and need for foley. Followup Instructions: ___
19830861-DS-10	19,830,861	22,289,857	DS	10	2159-02-19 00:00:00	2159-02-19 15:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right ankle pain Major Surgical or Invasive Procedure: Placement of external fixator device RLE History of Present Illness: This is a pleasant ___ M with no PMH presents with a severe R ankle injury sustained after being hit by a car while he was traversing a street. Endorses headstrike but no LOC. No neck pain. Severe pain in RLE and inability to bear weight. Past Medical History: Denies Social History: ___ Family History: NC Physical Exam: PE: AVSS A&O x 3 Calm and comfortable BUE skin clean and intact except for small abrasion over R elbow. No tenderness, deformity, erythema, edema, induration or ecchymosis Arms and forearms are soft No pain with passive motion R M U ___ EPL FPL EIP EDC FDP FDI fire 2+ radial pulses BLE skin clean and intact exceot abrasion over R lateral malleolus. Severe tenderness, deformity, erythema, edema around ankle joint. Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire 1+ ___ and DP pulses On discharge: ___ Gen: NAD, AAOx3 <<<<<<<<<<<<>>>>>>>>>> Pertinent Results: ___ 10:15PM BLOOD WBC-11.4* RBC-5.41 Hgb-17.1 Hct-49.0 MCV-91 MCH-31.6 MCHC-34.8 RDW-12.6 Plt ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient underwent imaging and was found to have a right ankle pilon fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for placement of external fixation device, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is Nonweightbearing in the Right Lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: Denies Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX acetaminophen 650 mg 1 tablet extended release(s) by mouth every six (6) hours Disp #40 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 3. Enoxaparin Sodium 30 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL ___t bedtime Disp #14 Syringe Refills:0 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Please do NOT drink alcohol, drive or operate heavy machinery while taking this medication. RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right pilon fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Change pin site dressings daily ACTIVITY AND WEIGHT BEARING: -NWB RLE with crutches Physical Therapy: Right Lower Extremity: Non-weightbearing with crutches; range of motion as tolerated. Followup Instructions: ___
19830918-DS-15	19,830,918	27,643,310	DS	15	2149-05-27 00:00:00	2149-05-28 17:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: back pain, L flank pain Major Surgical or Invasive Procedure: L semi-rigid ureteroscopy, L stent placement. History of Present Illness: ___ female with PMH notable for metastatic colon CA on experimental chemotherapy, bilateral nephrolithiasis s/p remote laser lithotripsy (w/ Dr. ___ who presents with L flank pain, found to have obstructing 3mm L proximal ureteric stone with mild hydronephrosis. Pt reports new onset L flank pain radiating to L groin last night, with associated mild nausea. She denies fevers/chills, emesis, SOB, CP, dysuria or hematuria. In the ED, initial vitals: T97.2 HR 65 BP 133/77 RR 19 100% RA. Patients exam was notable for severe pain, Left CVA tenderness. Labs were notable for: no leukocytosis, Cr 1.1 from baseline 0.8, UA non-infectious. Of note, pt had lactate 4.2 at presentation which decreased to 1 after IVF resuscitation. As above, CT abdomen was notable for 3 mm obstructing stone in the left proximal ureter causing upstream mild, hydroureteronephrosis with fluid tracking along the course of the left ureter and into the pelvis, bilateral non-obstructing renal stones, no evidence of mesenteric ischemia, multiple hepatic hypodense lesions not significantly changed from prior, stable omental caking and a moderate hiatal hernia. Patient received 4L IVF (2L NS, 1L ___, 1L D5NS), Dilaudid 1mg x4, Ondansetron IV 4mg, Ketorolac 15mg IV x 2, PO Tamsulosin 0.4mg. Urology was consulted, who recommended "no indication for urgent urologic intervention at this time. Recommend trial of medical expulsion therapy" with recommendation of Flomax, NSAIDs/Narcotics for pain control, hydration, po challenge, strain urine for passage of stone Pt was placed in ED obs overnight, but was still requiring IV narcotics. Decision was made to admit to Omed for PO challenge and pain control. On arrival to the floor, VS: T 98.1 BP 132 / 78 HR 77 RR 16 99% RA. Pt was complaining of severe back pain, as several hours had passed since she received her last dose of IV pain medication. Pt was given 1x dose of Dilaudid 1MG IV to relieve her acute symptoms, and was assessed on the floor for further kidney stone /pain management. Past Medical History: ONCOLOGY HISTORY: Ms. ___ initially began feeling unwell the end of ___. She noticed swelling in her stomach with associated shooting abdominal pain. She additionally noticed changes in her bowel habits and constipation. She underwent a colonoscopy on ___ which showed a mass in the ascending colon showing moderately differentiated invasive adenocarcinoma with overlying normal mucosa. Tumor cells are immunoreactive for CDX2 and negative for CK-7, CK-20, WT-1, ER, TTF-1, PAX8, PAX2, mammoglobin, and GCDFP. Additionally, KRAS mutation was not detected on her biopsy and MSI testing showed intact expression of MLH-1, PMS-2, MSH-2 and MSH-6. EGD was also done due to some dysphagia she was experiencing and revealed ___ mucosa. A CT of her abd/pelvis on ___ revealed the ascending colon mass along with omental caking and 2 hepatic hypodensities that were incompletely characterized. CT chest on ___ showed tiny right diaphragmatic lymph nodes that could be an early manifestation of malignancy the where clearly not pathologically enlarged. Small left thyroid nodule also visualized and u/s is recommended. On ___, PET scan revealed known ascending colon mass demonstrates intense FDG uptake with SUV max 21.6, diffuse omental caking and nodularity, demonstrating intense FDG uptake, with SUV max 10.2, compatible with metastatic disease, multiple foci of intense FDG uptake in the liver, compatible with metastases, and an asymmetric small focus of FDG uptake in the region of the right lingual tonsil, which may be reactive. Additionally on ___, MRI of liver demonstrated at least 4 liver lesions as detailed above consistent with metastatic disease, further metastatic disease in the abdomen with partially visualized omental caking and early implants along the right liver edge, and a 4 mm pancreatic tail side-branch IPMN. She underwent tissue bx with cytology of a R omentum lesion on ___ which was positive for malignant cells. She also had a SL POC placed in ___ on ___ for chemo initiation. Since her PET scan revealed some uptake in her R lingual tonsil, she underwent a thyroid u/s on ___ which recommended a bx of a left lower pole nodule due to its size. FNA was performed on ___ at the ___ thyroid clinic which was benign and consistent with a macrofollicular lesion. Recent CT on ___ of her chest/abd for staging showed ascending colon neoplasia with worsened hepatic and omental metastases since the CT from ___, but unchanged from the previous MRI from ___ and no evidence of metastatic disease in the thorax. - ___ FOLFOX/Avastin/Vitamin D - ___ FOLFOX/Avastin/Vitamin D - neupogen added due to late nadir. Patient experienced tongue swelling and lisp shortly after receiving oxaliplatin. - ___ FOLFOX/Avastin/Vitamin D HELD due to need to coordinate oxaliplatin desensitization on inpatient unit - ___ FOLFOX/Avastin/Vitamin D with oxaliplatin desensitization - ___ CT torso: stable disease - ___ held ___ neutropenia - ___ held ___ neutropenia OTHER PAST MEDICAL HISTORY: 1. Metastatic colon cancer as above 2. Rheumatoid arthritis, managed with MTX and Humira 3. Osteoarthritis 4. Hyperlipidemia 5. Nephrolithiasis 6. Hx SCC and BCC 7. Shingles 8. Ocular migraines 9. Actinic Keratoses, managed with ___ PAST SURGICAL HISTORY: 1. Total Abdominal Hysterectomy in ___ 2. Gastric Lap Band in ___ 3. Lithrotripsy in ___ 4. MOHS of R neck basal cell in ___ 5. Skin biopsies left ant and med tibia, left preauricular basal cell in ___ 6. Left knee menisectomy in ___ 7. Rhinoplasty for chronic sinusitis in ___ 8. Tonsillectomy in ___ Social History: ___ Family History: Significant for two cousins who have colon cancer, father with prostate cancer, maternal uncle with pancreatic cancer, and MGM with cervical cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T98.1 BP 132 / 78 HR 77 RR 16 99% RA GENERAL: Lying in bed, uncomfortable lying still in pain HEENT: MMM, no LAD, 3mm->2mm CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly Back: +CVA tenderness, tenderness from L mid back to L flank and extending down the L anterior abdomen towards the groin. EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses NEURO: Alert, oriented, CN II-XII intact. Intact sensation to LT bilaterally. Strength ___ b/l UE and ___. 2+ DTRs SKIN: No significant rashes DISCHARGE PHYSICAL EXAM: ======================== PHYSICAL EXAM: VS: T 98.0 BP 130 / 70 HR 72 RR 20 96% RA GENERAL: Lying in bed, comfortable HEENT: MMM, no LAD. CARDIAC: RRR, no MRGs; normal S1/S2. CHEST: R port site access, c/d/i. LUNG: CTA b/l; no wheezes, rhonchi, or rales. ABD: Soft, non-tender, non-distended, NABS. EXT: Warm, well perfused, no lower extremity edema NEURO: Alert, oriented, CN II-XII intact. SKIN: No significant rashes BACK: No CVA tenderness Pertinent Results: ADMISSION LABS: =============== ___ 01:03AM BLOOD WBC-5.1 RBC-3.02* Hgb-9.0* Hct-28.5* MCV-94 MCH-29.8 MCHC-31.6* RDW-19.1* RDWSD-65.5* Plt ___ ___ 01:03AM BLOOD Neuts-72.1* Lymphs-17.6* Monos-5.1 Eos-3.4 Baso-0.6 Im ___ AbsNeut-3.64# AbsLymp-0.89* AbsMono-0.26 AbsEos-0.17 AbsBaso-0.03 ___ 01:03AM BLOOD ___ PTT-22.0* ___ ___ 01:03AM BLOOD Glucose-110* UreaN-17 Creat-1.1 Na-140 K-3.4 Cl-105 HCO3-18* AnGap-20 ___ 01:03AM BLOOD ALT-37 AST-53* AlkPhos-128* TotBili-0.5 ___ 01:03AM BLOOD Lipase-81* ___ 01:03AM BLOOD Albumin-4.2 ___ 01:13AM BLOOD Lactate-4.2* DISCHARGE LABS: =============== ___ 06:15AM BLOOD WBC-14.7* RBC-2.63* Hgb-7.7* Hct-24.2* MCV-92 MCH-29.3 MCHC-31.8* RDW-18.9* RDWSD-63.7* Plt Ct-65* ___ 05:30AM BLOOD Neuts-92* Bands-1 Lymphs-4* Monos-0 Eos-2 Baso-1 ___ Myelos-0 AbsNeut-15.07* AbsLymp-0.65* AbsMono-0.00* AbsEos-0.32 AbsBaso-0.16* ___ 05:51AM BLOOD ___ PTT-25.4 ___ ___ 06:15AM BLOOD Glucose-85 UreaN-6 Creat-0.6 Na-140 K-3.7 Cl-107 HCO3-25 AnGap-12 ___ 05:30AM BLOOD ALT-20 AST-26 LD(LDH)-250 AlkPhos-98 TotBili-0.6 ___ 01:03AM BLOOD Lipase-81* ___ 06:15AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 IMAGING: ======== + CTA Abd & Pelvis (___): 1. 3 mm obstructing stone in the left proximal ureter causing upstream mild hydroureteronephrosis. There is fluid tracking along the course of the left ureter and into the pelvis. Of note, IV contrast has not yet been excreted into the ureter. 2. No evidence of mesenteric ischemia. 3. Multiple hepatic hypodense lesions have not significantly changed. 4. Stable omental caking, as compared to prior. + CT CHEST (___): 1. Multiple ill-defined small ground-glass opacities with subpleural predominance are new. Findings may reflect early manifestation of drug toxicity. Other possible etiologies include atypical/opportunistic infection or inflammatory process, including organizing pneumonia. Atypical manifestation of metastasis is less likely. 2. Several pulmonary nodules measuring 2 mm or less are stable. + KUB (___): 1. Multiple bilateral renal radiopaque densities consistent with renal calculi. 2. Gaseous colonic distention. 3. Phleboliths in the lower pelvis. Brief Hospital Course: Mrs. ___ is a ___ year old female with rheumatoid arthritis and metastatic colon cancer to liver and omentum on phase II trial of vitamin D vs. placebo with allergic reaction s/p C16 of ___ FOLFOX/Avastin/Vitamin D who presented with L flank pain radiating to the groin, found to have obstructing 3mm L proximal uteteric stone with mild hydronephrosis, and admitted to ___ for pain control and medical mgmt of kidney stone. # Nephrolithiasis: On admission patient presented with L flank pain, found to have obstructing 3mm L proximal ureteric stone with mild hydronephrosis, periureteric edema most likely reactive in nature. His initial labs were notable for a normal WBC count, no ___ and UA with RBC >182, 1+ hyaline cast but otherwise no leuk esterase/nitrites or WBCs in the urine. During this admission pt remained afebrile, HD stable, w/o leukocytosis or ___, and with UA notable for RBCs but otherwise non-infectious. Patient was medically managed to pass her stone, and was started on Tamsulosin 0.4 mg PO QHS which was continued until the stone was passed, IVF hydration ___ NS at 200cc/hr) and her pain was controlled with Tylenol, Ketorolac 15mg IV, Dilaudid PCA 0.12mg q6min, 1.2mg max per hour and Dilaudid IV 1mg Q2H PRN for breakthrough pain. Her nausea was controlled with Ondansetron ___ mg IV q8h prn. She was unable to pass her stone, so she was taken for uterescopy with urology. During this procedure, the stone could not be visualized, and so lithotripsy was aborted, and a ureteral stent was placed. Patient did well with stent in place, with reduced need for oral pain medications. Pt will continue to take Flomax as an outpatient and will followup with urology in ___ weeks after discharge to assess for passage of stone vs a ___ trial of lithrotripsy. Etiology of stone was unclear as she has history of nephrolithiasis but is also on Vitamin D, which may theoretically exacerbate calcium oxoalate stones. A KUB showed multiple radiopaque renal caliculi consistent with calcium stones. 24H urine collection had predominance of uric acid over calcium. As the stone was not passed during admission she was discharged with instructions to continue straining urine and to bring stone in for pathology. # Colon Cancer metastatic to omentum and liver: On admission, patient had just finished her most recent round of FOLFOX/Avastin/Vitamin D while waiting in ED. She was monitored for nadir of WBC, and was started on Neupogen. Plan was made for patient to continue her neupogen until followup with her primary oncologist, during which time a decision would be made to continue or d/c Neupogen. Vitamin D was discontinued during stay given possible contribution to nephrolithiasis. # Rheumatoid arthritis/osteoarthritis: During this admission, pts RA was managed with patients home dose hydroxychloroquine, but her meloxicam was held as an inpatient, with plan to resume meloxicam after discussion with her PCP. #Hyperlipidemia: During this admission, pt was continued on home simvastatin 10mg QPM # Mood disturbance: During this admission, pt was continued on home Sertraline 25 mg qD and Lorazepam 1 mg po q6h for anxiety relief. #GERD: During this admission, pt was continued on home Ranitidine 150 mg PO DAILY. TRANSITIONAL ISSUES: ========================== - please followup in outpatient in ___ clinic in ~2wks to discuss definitive stone management/stent removal - Please ensure urine is strained. Once stone passed it should be sent to pathology for further analysis. - Research supply of blinded Vitamin D was discontinued during hospitalization given possible contribution to stone formation. - Please follow-up pts CBC to determine continued use of Neupogen. Pt is s/p C16 of AVASTIN/FOLFOX/Vitamin D, and was started on Neupogen in setting of dropping WBC and concern for reaching a nadir. - Please follow-up staging scan obtained during her hospital visit as part of her AVASTIN/FOLFOX/VITAMIN D trial. - Please followup final read of KUB for calcium vs uric acid stone Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Prochlorperazine 10 mg PO Q8H:PRN nausea 3. Hydroxychloroquine Sulfate 200 mg PO DAILY 4. Docusate Sodium 100 mg PO TID 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Senna 17.2 mg PO QHS 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Ranitidine 150 mg PO DAILY 9. Simvastatin 10 mg PO QPM 10. Spironolactone 25 mg PO DAILY 11. meloxicam 15 mg oral DAILY 12. Omeprazole 20 mg PO BID 13. Loratadine 10 mg PO DAILY 14. Sertraline 25 mg PO DAILY 15. Pyridoxine 50 mg PO DAILY 16. LORazepam 0.5-1 mg PO Q4H:PRN nausea, anxiety, insomnia Discharge Medications: 1. Filgrastim 480 mcg SC Q24H 2. Docusate Sodium 100 mg PO TID 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Hydroxychloroquine Sulfate 200 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. LORazepam 0.5-1 mg PO Q4H:PRN nausea, anxiety, insomnia 7. Omeprazole 20 mg PO BID 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Prochlorperazine 10 mg PO Q8H:PRN nausea 11. Pyridoxine 50 mg PO DAILY 12. Ranitidine 150 mg PO DAILY 13. Senna 17.2 mg PO QHS 14. Sertraline 25 mg PO DAILY 15. Simvastatin 10 mg PO QPM 16. Spironolactone 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Nephrolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking care of you during your recent admission to ___. You were admitted due to severe L flank pain and were found on CT imaging to have a 3mm kidney stone in the L ureter. You were assessed by urology in the hospital, who elected no immediate intervention. You were treated on the oncology medicine service with Tamsulosin and IV fluids to help you pass the stone, and were given pain control with Dilaudid IV medication. You were further given medications to help with your nausea. Our urologists placed a stent into your ureter to aid in passing your stone. You should continue straining your urine until you have passed the stone and then bring it in for pathology to analyze. Finally you should followup with Urology as an outpatient to discuss stone management and stent removal. During your stay, you were also started on Neupogen as you had recently completed your most recent round of chemotherapy (FOLFOX/Avastin/Vit D). You will followup with your primary oncologist to ensure that your cell counts continue to improve. Please followup with the appointments below that have been setup on your behalf. Once again, it was a pleasure to take care of you during your stay. We wish you the best! Your ___ team Followup Instructions: ___
19830918-DS-16	19,830,918	20,715,041	DS	16	2149-08-30 00:00:00	2149-08-30 22:54:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___ Chief Complaint: Flank pain, nephrolithiasis Major Surgical or Invasive Procedure: ___ Bilateral double-J ureteral stent placement, ___ by 26 cm were placed History of Present Illness: ___ female with PMH notable for metastatic colon CA actively on chemotherapy, bilateral nephrolithiasis s/p remote laser lithotripsy (w/ Dr. ___ and more recent left ureteral stent in ___ for left sided stone and ___. Patient presented to ER early this morning for severe left flank pain. She has been taking Macrobid for 2 days for presumed UTI (no culture result in our system) for suprapubic pressure. CT abd/pelvis (my read): ~4mm left distal ureteral stone with moderate hydro. R sided peripelvic cysts without hydro. Multiple non-obstruction stones in bilateral kidneys. Urology took patient to OR ___, Bilateral double-J ureteral stent placement, ___ by 26 cm were placed. Her pain is currently much better with narcotics. Patient's Last chemo dose was ___. She started Nulesta ___ and is due to receive 6 injections. Labs in the AM prior to her procedure were notable for WBC 41K, lactate 4, BUN 21, Cr 0.8. Labs checked after the procedure were notable for a downtrending H/H from 11 to 9, downtrending plts 130 to 80 and downtrending white count from 48 to 30. Lactate resolved to 1.7. UA 4.2. LFTs wnl. LDH slightly elevated at 268. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: ONCOLOGY HISTORY: Ms. ___ initially began feeling unwell the end of ___. She noticed swelling in her stomach with associated shooting abdominal pain. She additionally noticed changes in her bowel habits and constipation. She underwent a colonoscopy on ___ which showed a mass in the ascending colon showing moderately differentiated invasive adenocarcinoma with overlying normal mucosa. Tumor cells are immunoreactive for CDX2 and negative for CK-7, CK-20, WT-1, ER, TTF-1, PAX8, PAX2, mammoglobin, and GCDFP. Additionally, KRAS mutation was not detected on her biopsy and MSI testing showed intact expression of MLH-1, PMS-2, MSH-2 and MSH-6. EGD was also done due to some dysphagia she was experiencing and revealed ___ mucosa. A CT of her abd/pelvis on ___ revealed the ascending colon mass along with omental caking and 2 hepatic hypodensities that were incompletely characterized. CT chest on ___ showed tiny right diaphragmatic lymph nodes that could be an early manifestation of malignancy the where clearly not pathologically enlarged. Small left thyroid nodule also visualized and u/s is recommended. On ___, PET scan revealed known ascending colon mass demonstrates intense FDG uptake with SUV max 21.6, diffuse omental caking and nodularity, demonstrating intense FDG uptake, with SUV max 10.2, compatible with metastatic disease, multiple foci of intense FDG uptake in the liver, compatible with metastases, and an asymmetric small focus of FDG uptake in the region of the right lingual tonsil, which may be reactive. Additionally on ___, MRI of liver demonstrated at least 4 liver lesions as detailed above consistent with metastatic disease, further metastatic disease in the abdomen with partially visualized omental caking and early implants along the right liver edge, and a 4 mm pancreatic tail side-branch IPMN. She underwent tissue bx with cytology of a R omentum lesion on ___ which was positive for malignant cells. She also had a SL POC placed in ___ on ___ for chemo initiation. Since her PET scan revealed some uptake in her R lingual tonsil, she underwent a thyroid u/s on ___ which recommended a bx of a left lower pole nodule due to its size. FNA was performed on ___ at the ___ thyroid clinic which was benign and consistent with a macrofollicular lesion. Recent CT on ___ of her chest/abd for staging showed ascending colon neoplasia with worsened hepatic and omental metastases since the CT from ___, but unchanged from the previous MRI from ___ and no evidence of metastatic disease in the thorax. - ___ FOLFOX/Avastin/Vitamin D - ___ FOLFOX/Avastin/Vitamin D - neupogen added due to late nadir. Patient experienced tongue swelling and lisp shortly after receiving oxaliplatin. - ___ FOLFOX/Avastin/Vitamin D HELD due to need to coordinate oxaliplatin desensitization on inpatient unit - ___ FOLFOX/Avastin/Vitamin D with oxaliplatin desensitization - ___ CT torso: stable disease - ___ held ___ neutropenia - ___ held ___ neutropenia OTHER PAST MEDICAL HISTORY: 1. Metastatic colon cancer as above 2. Rheumatoid arthritis, managed with MTX and Humira 3. Osteoarthritis 4. Hyperlipidemia 5. Nephrolithiasis 6. Hx SCC and BCC 7. Shingles 8. Ocular migraines 9. Actinic Keratoses, managed with Aldara PAST SURGICAL HISTORY: 1. Total Abdominal Hysterectomy in ___ 2. Gastric Lap Band in ___ 3. Lithrotripsy in ___ 4. MOHS of R neck basal cell in ___ 5. Skin biopsies left ant and med tibia, left preauricular basal cell in ___ 6. Left knee menisectomy in ___ 7. Rhinoplasty for chronic sinusitis in ___ 8. Tonsillectomy in ___ Social History: ___ Family History: Significant for two cousins who have colon cancer, father with prostate cancer, maternal uncle with pancreatic cancer, and MGM with cervical cancer. Physical Exam: Admission PE: Vitals: 98.0F PO BP 138/70 L Sitting HR 83 RR 18 98 RA General: Well-appearing female in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple Lymph: No palpable cervical or supraclavicular lymphadenopathy Chest: Right-sided port. Dressing clean/dry/intact. CV: RRR, nl S1/S2, no MRG Pulm: CTAB, no wheezes/rales/rhonchi, normal effort Abd: Soft, NTND, positive bowel sounds Back: No spinal tenderness Ext: Warm, well-perfused, trace lower extremity edema bilaterally Neuro: AAOx3, CN II-XII grossly intact, sensation and two point discrimination fully intact in palms, sensation and two point discrimination decreased to mid-lower legs bilaterally. This is stable from last exam. Skin: No obvious rashes, no concerning lesions Discharge PE: Vitals: 98.4 POBP 126/84 HR 89 RR 18 O2 99% RA General: Well-appearing lady, NAD HEENT: Sclerae anicteric, MMM, OP clear Neck: Supple Lymph: No palpable cervical or supraclavicular lymphadenopathy Chest: Right-sided port. Dressing clean/dry/intact. CV: RRR, nl S1/S2, no MRG Pulm: CTAB, no wheezes/rales/rhonchi, breathing nonlabored Abd: Soft, NTND, NABS, no suprapubic tenderness Back: No spinal tenderness Ext: Warm, well-perfused, trace lower extremity edema bilaterally Neuro: AAOx3, CN II-XII grossly intact Skin: No obvious rashes, no concerning lesions Pertinent Results: ================ LABS ON ADMISSION ================ ___ 06:52PM GLUCOSE-122* UREA N-16 CREAT-0.8 SODIUM-138 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 ___ 06:52PM ALT(SGPT)-21 AST(SGOT)-25 LD(LDH)-268* ALK PHOS-136* TOT BILI-0.6 ___ 06:52PM ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.9 URIC ACID-4.2 IRON-100 ___ 06:52PM ___ PO2-63* PCO2-46* PH-7.31* TOTAL CO2-24 BASE XS--3 ___ 06:52PM LACTATE-1.7 ___ 06:52PM WBC-31.5* RBC-3.00* HGB-9.6* HCT-30.3* MCV-101* MCH-32.0 MCHC-31.7* RDW-16.4* RDWSD-60.3* ___ 06:52PM NEUTS-93* BANDS-1 LYMPHS-4* MONOS-2* EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-29.61* AbsLymp-1.26 AbsMono-0.63 AbsEos-0.00* AbsBaso-0.00* ___ 06:52PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL TEARDROP-1+ ___ 06:52PM PLT SMR-LOW PLT COUNT-80* ___ 06:52PM ___ PTT-25.7 ___ ___ 10:55AM URINE HOURS-RANDOM =============== LABS ON DISCHARGE =============== ___ 07:30AM BLOOD WBC-19.6* RBC-2.87* Hgb-9.1* Hct-29.1* MCV-101* MCH-31.7 MCHC-31.3* RDW-16.6* RDWSD-61.6* Plt Ct-80* ___ 07:30AM BLOOD Neuts-90.4* Lymphs-6.7* Monos-1.1* Eos-0.3* Baso-0.2 Im ___ AbsNeut-17.72* AbsLymp-1.32 AbsMono-0.22 AbsEos-0.05 AbsBaso-0.04 ___ 07:30AM BLOOD Plt Ct-80* ___ 07:30AM BLOOD ___ PTT-26.8 ___ ___ 07:30AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-140 K-4.7 Cl-107 HCO3-24 AnGap-14 ___ 07:30AM BLOOD ALT-19 AST-23 LD(LDH)-259* AlkPhos-137* TotBili-0.6 ___ 07:30AM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.0 Mg-2.2 =========== MICRO =========== URINE CULTURE (Final ___: NO GROWTH. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. =============== Imaging ============== ___ CT abd/pelvis 1. 3 mm left distal ureteric calculus causing low-grade obstruction with mild left hydronephrosis and mild left periureteral fat stranding but no delayed nephrogram is seen. No right hydronephrosis. 2. Multiple bilateral nonobstructing renal calculi measuring up to 4 mm. 3. Left lateral renal cortical scarring is unchanged. ___ Renal US 1. Moderate left hydronephrosis with an obstructing distal left ureteral stone measuring up to 5 mm. Additional nonobstructing left-sided renal stones measure up to 1 cm. 2. Mild right hydronephrosis with multiple nonobstructing renal stones measuring up to 6 mm. Brief Hospital Course: ___ female with PMH notable for metastatic colon CA actively on chemotherapy, bilateral nephrolithiasis s/p remote laser lithotripsy (w/ Dr. ___ and more recent left ureteral stent in ___ for left sided stone and ___. Patient presented to ER early this morning for severe left flank pain. She has been taking Macrobid for 2 days for presumed UTI (no culture result in our system) for suprapubic pressure. CT abd/pelvis (my read): ~4mm left distal ureteral stone with moderate hydro. R sided peripelvic cysts without hydro. Multiple non-obstruction stones in bilateral kidneys. Urology took patient to OR ___, Bilateral double-J ureteral stent placement, ___ by 26 cm were placed. # Obstructing kidney stone: on ___, patient consented for emergent cystosccopy and bilateral ureteral stents placed by urology. d/c with 7d course of Cefpodoxime per urology with outpatient urology f/u. #UTI: On macrobid prior to admission started ___ for suprapubic fullness. UA with WBCs, started CTX ___, transitioned to 7day course of Cefpodoxime on dc; UCx finalized showing no growth. # Thrombocytopenia, chronic, stable: in the setting of procedures, nephrolithiasis and now 5 days s/p chemotherapy. # Anemia: Hgb on admission 11 downtrended to 9 in post procedure setting. Hemodynamically stable. Likely hemodiluation vs. minor blood loss from procedure. IV access was maintained, active T&S. # Colon Cancer metastatic to omentum and liver: On admission, patient C1D5 FOLFOX/Avastin/Vitamin D. Six-day course of neupogen started ___, to be completed ___. # Rheumatoid arthritis/osteoarthritis: Continued home dose hydroxychloroquine, but her meloxicam was held as an inpatient, with plan to resume meloxicam after discussion with her PCP. #Hyperlipidemia: continued simvastatin 10mg QPM #GERD: Continued Ranitidine 150 mg PO DAILY, and Omeprazole 20 mg PO daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 2 SPRY NU DAILY 2. Hydroxychloroquine Sulfate 200 mg PO DAILY 3. Loratadine 10 mg PO DAILY 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Pyridoxine 50 mg PO DAILY 6. Ranitidine 150 mg PO DAILY 7. Simvastatin 10 mg PO QPM 8. Spironolactone 25 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Omeprazole 20 mg PO BID 11. Senna 17.2 mg PO QHS 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. Filgrastim 480 mcg SC Q24H 14. meloxicam 15 mg oral DAILY 15. DULoxetine 60 mg PO QHS Discharge Medications: 1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 7 Days RX cefpodoxime 100 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. DULoxetine 60 mg PO QHS 4. Filgrastim 480 mcg SC Q24H 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Hydroxychloroquine Sulfate 200 mg PO DAILY 7. Loratadine 10 mg PO DAILY 8. meloxicam 15 mg oral DAILY 9. Omeprazole 20 mg PO BID 10. Ondansetron 8 mg PO Q8H:PRN nausea 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Pyridoxine 50 mg PO DAILY 13. Ranitidine 150 mg PO DAILY 14. Senna 17.2 mg PO QHS 15. Simvastatin 10 mg PO QPM 16. Spironolactone 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: bilateral Nephrolithiasis Hydronephrosis Urinary tract infection Metastatic Colon Cancer Rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ found to have a kidney stone. The urologists placed stents in the tubes that drain urine from your kidney to your bladder called ureters (bilateral ureteral stents) to relieve you from the discomfort of the stones. We are treating your urinary tract infection with an antibiotic called Cefpodoxime. You should take this antibiotic for 7 days. You will also need follow-up in ___ clinic. The urology office will call you to schedule this but if you do not hear from them by the end of this week, call their office at ___. Thank you for allowing us to participate in your care ___ Care team Followup Instructions: ___
19830951-DS-25	19,830,951	24,274,290	DS	25	2128-04-30 00:00:00	2128-05-01 20:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Enalapril / Januvia / felodipine Attending: ___. Chief Complaint: Right leg pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an ___ with PMHx of HTN, HLD, Diastolic HF, diet-controlled DM, and Stage 4 CKD who presents from how with weakness in the legs and cough. Patient reports that weakness she experience in the legs is likely ___ her right knee, specifcally below the right knee. The weakness that she experiences has been affecting her ability to walk, and she can no longer drive a car. The patient reports that ___ years ago, she had a fracture in the right knee and had pins placed there. The pins have since been removed. The patient states that she has OA now; her pain has not increased recently in the right knee. She denies locking of the joint or slippage of the joint with walking. He denies erythema, warmth, or redness to the joints of the lower extremities. She denies trauma or recent falls. She denies dizziness or lightheaded when going from a seated to standing position. She had been working at ___ working on strengthening but she has not been back since ___. The patient reports that her only medication change has been an increase in Clonidine patch, now using 2 patches instead of 1 patch. The patient denies poor appetite. She has also developped a non-productive cough since ___. The cough feels as if it arises from the throat. She denies fevers/chills prior to admission. She denies a sore throat. She reports nasal congestion at baseline likely secondary to seasonal allergies. She denies rhinorrhea. She denies rash. She denies associated shortness of breath or pleuritic chest pain. In the ED initial vitals were: 0 99.4 73 193/71 18 98% RA. Patient noted to have fever to 101.4 in the ED. - Labs were significant for Na 148, HCO3 16, BUN 47, Cr 2.4, HCT 30.3, lactate 1.4. Protein noted on UA. - Radiology: ___: No evidence of hemorrhage or acute territorial infarction. CXR: Small bilateral effusions and mild interstitial edema without confluent consolidation. - Patient was given APAP 1000mg, Labetalol 200mg ONCE, and Hydralazine 50mg PO once. Vitals prior to transfer were: 0 99.4 57 141/62 18 95% RA On the floor, the patient is laying in bed in NAD. Past Medical History: 1. Type 2 diabetes, well controlled off diabetes medications 2. Hypertension, which has been difficult to control. 3. Diastolic CHF. 4. Hyperlipidemia. 5. Incidentally discovered syrinx from C1-T10 with a watchful waiting approach. 6. Osteoporosis. 7. Obstructive sleep apnea, intermittently on CPAP. 8. Chronic kidney disease stage IV, followed by Dr. ___. 9. Gout. 10. Episode of severe hypercalcemia, ___. 11. History of right knee fracture status post pin placement and now removal. Social History: ___ Family History: Aunt with diabetes. No known family history of MI or stroke that patient could remember. Son is s/p 2 kidney transplants ___ glomerulonephritis Father died young of cerbral hemorrhaage. Mother also died young of complications of pneumona. CAD and vascular disease in various other members. aneurysm and a third with an MI. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - T: 98.4 BP: 176/56 HR: 66 RR: 20 02 sat: 96% on RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, dryMM, good dentition, NECK: nontender supple neck, no LAD, no appreciated JVD CARDIAC: RRR, S1/S2, ___ systolic murmur appreciated best at the LLSB and cardiac apex. No appreciated gallops or rubs LUNG: Nml WOB without accessory muscle use. Diffuse wheezing bilaterally, with no focal crackles appreciated. ABDOMEN: Distended, +BS, nontender in all quadrants EXTREMITIES: moving all extremities well, no cyanosis, clubbing. Trace pitting edema of the shins bilaterally. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. ___ bicpes and triceps strength bilaterally. ___ strength at the hip flexors bilaterally. ___ dorsiflexion and plantar flexion at the ankles bilaterally. KNEE: Right knee with overlying scar that is well-healed. TTP along the medial and lateral joint spaces. Crepitus appreciated. Difficult to manuever right knee secondary to stiffness. SKIN: No appreciated lesions or rashes. Clonidine patch noted on the right and left deltoids. DISCHARGE PHYSICAL EXAM: Vitals - T: 98.4 BP: 168/80 HR: 66 RR: 20 02 sat: 96% on RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, dryMM, good dentition, NECK: nontender supple neck, no LAD, no appreciated JVD CARDIAC: RRR, S1/S2, ___ systolic murmur appreciated best at the LLSB and cardiac apex. No appreciated gallops or rubs LUNG: Nml WOB without accessory muscle use. Diffuse wheezing bilaterally, with no focal crackles appreciated. ABDOMEN: Distended, +BS, nontender in all quadrants EXTREMITIES: moving all extremities well, no cyanosis, clubbing. Trace pitting edema of the shins bilaterally. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. ___ bicpes and triceps strength bilaterally. ___ strength at the hip flexors bilaterally. ___ dorsiflexion and plantar flexion at the ankles bilaterally. KNEE: Right knee with overlying scar that is well-healed. TTP along the medial and lateral joint spaces. Crepitus appreciated. Difficult to manuever right knee secondary to stiffness. SKIN: No appreciated lesions or rashes. Clonidine patch noted on the right and left deltoids. Pertinent Results: ADMISSION LABS: ___ 01:35PM BLOOD WBC-7.9 RBC-3.02* Hgb-9.6* Hct-30.3* MCV-100* MCH-31.8 MCHC-31.8 RDW-17.5* Plt ___ ___ 01:35PM BLOOD Neuts-75.9* Lymphs-16.3* Monos-6.4 Eos-0.9 Baso-0.4 ___ 01:35PM BLOOD Glucose-123* UreaN-47* Creat-2.4* Na-148* K-4.7 Cl-118* HCO3-16* AnGap-19 ___ 05:08PM BLOOD Lactate-1.4 ___ 04:55PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04:55PM URINE Blood-MOD Nitrite-NEG Protein-600 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 04:55PM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 MICRO: ___ 5:16 pm URINE Site: NOT SPECIFIED ADDED TO GRAY HOLD ___ - ___. *FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. IMAGING: CXR: FINDINGS: AP and lateral views of the chest. Left-sided subclavian line is no longer visualized. There is blunting of the posterior costophrenic angles suggestive of small effusion. Mildly indistinct pulmonary vascular markings are seen. There is no confluent consolidation. Cardiac silhouette is enlarged but stable in configuration. Tortuous descending thoracic aorta is noted. Degenerative change is seen at the shoulders bilaterally. IMPRESSION: Small bilateral effusions and mild interstitial edema without confluent consolidation. HEAD CT: IMPRESSION: No evidence of hemorrhage or acute territorial infarction. RIGHT KNEE XRAY: FINDINGS: No previous images. There is some compression about the lateral tibial plateau, consistent with the history of old fracture. Generalized osteopenia is seen. There is some medial displacement of the distal femur with respect to the proximal tibia. Substantial narrowing with hypertrophic spurring is seen in the patellofemoral compartment. DISCHARGE LABS: ___ 06:53AM BLOOD WBC-7.0 RBC-3.04 Hgb-9.2* Hct-31.0* MCV-102* MCH-30.4 MCHC-29.8* RDW-17.9* Plt ___ ___ 06:53AM BLOOD Glucose-105* UreaN-60* Creat-2.4* Na-143 K-4.3 Cl-113* HCO3-17* AnGap-17 Brief Hospital Course: Patient is an ___ year old female with history of hypertension, hyperlipidemia, diastolic heart failure, diabetes and stage 4 chronic kidney disease who presents with weakness in the legs and cough. ACTIVE ISSUES ------------ # Weakness: Differential diagnosis included general weakness secondary to underlying infection versus knee instability versus dehydration. If not one of these clinical entities, then it is possible that these clinical entities together may have contributed to the patient's clinical picture. Orthostatic vital signs were negative. X-ray of the right knee showed chronic arthritic changes. ___ evaluated the patient and recommended home with ___ and ___ services. # Fever: Patient with one documented fever in the ED to 101.4 for which the patient received acetaminophen. Differential diagnosis included viral URI in light of recent cough versus pneumonia (though no focal consolidation present) versus urinary tract infection. UA and urine culture were negative. Patient's fever and cough most likely consistent with viral URI. Patient remained afebrile throughout her hospitalization. # Cough: Patient with cough with evidence of small bilateral pleural effusions on CXR. Viral URI is most likely diagnosis. # Hypernatremia: Likely secondary to dehydration. Furosemide was held, and patient was encouraged to take PO, after which sodium trended down to 143. INACTIVE ISSUES -------------- # Chronic kidney disease: Patient with metabolic acidosis, which likely secondary to underlying kidney disease. Patient is on bicarbonate tabs as an outpatient. Creatinine has recently been 2.4 as an outpatient and creatinine remained stable during her admission. # Hypertension: Per PCP documentation, patient with difficult to control blood pressure. Patient's clonidine patch was recently increased in light of persistently elevated blood pressure at outpatient appointments to two patches. Patient was continued on hydralazine, losartan, and labetalol at home dosing as well as clonidine patch. Furosemide was held but restarted on discharge. # Anemia: hematocrit stable. She receives darbepoetin alfa as an outpatient. # Hyperlipidemia: patient was continued on her statin. # Diabetes: Patient not on oral mediations nor insulin as an outpatient. TRANSITIONAL ISSUES: [ ] Please follow-up final blood cultures from ___ [ ] Please follow-up blood cultures from ___ [ ] Please ensure patient has appropriate home services and ___ at home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Clonidine Patch 0.1 mg/24 hr 2 PTCH TD 1X/WEEK (MO) 3. darbepoetin alfa in polysorbat 60 mcg/mL injection Every 4 weeks 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Furosemide 20 mg PO DAILY 6. Gabapentin 300 mg PO DAILY 7. HydrALAzine 50 mg PO TID 8. Labetalol 200 mg PO TID 9. Losartan Potassium 100 mg PO DAILY 10. Potassium Chloride 10 mEq PO DAILY 11. Simvastatin 40 mg PO DAILY 12. Aspirin 325 mg PO DAILY 13. Vitamin D 400 UNIT PO DAILY 14. Ferrous GLUCONATE 240 mg PO DAILY 15. Sodium Bicarbonate 650 mg PO BID Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Clonidine Patch 0.1 mg/24 hr 2 PTCH TD 1X/WEEK (MO) 4. Ferrous GLUCONATE 240 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. HydrALAzine 50 mg PO TID 7. Labetalol 200 mg PO TID 8. Losartan Potassium 100 mg PO DAILY 9. Simvastatin 40 mg PO DAILY 10. Sodium Bicarbonate 650 mg PO BID 11. Vitamin D 400 UNIT PO DAILY 12. darbepoetin alfa in polysorbat 60 mcg/mL injection Every 4 weeks 13. Furosemide 20 mg PO DAILY 14. Gabapentin 300 mg PO DAILY 15. Potassium Chloride 10 mEq PO DAILY Hold for K > Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: weakness SECONDARY DIAGNOSES: osteoarthritis, chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___ was a pleasure taking care of you at ___. You were admitted with weakness, likely due to a viral upper respiratory infection. You had an Xray that showed chronic arthritis changes. Please keep your follow up appointments as below. Please return to the emergency room if you experience fevers, chills, chest pain, shortness of breath, or any other new or concerning symptoms. We wish you the best, Your ___ team Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
19830951-DS-27	19,830,951	28,715,053	DS	27	2129-03-30 00:00:00	2129-03-30 19:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Enalapril / Januvia / felodipine Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F with multiple medical problems here with BLE weakness found to be due to an L4 vertebral fracture. Patient called PCP yesterday complaining of BLE weakness. She uses walker at baseline, but over the ___ hours prior to presentation she had been unable to get out of bed. There was no lateralization or upper extremity symptoms. At some point, patient rolled out of bed and hit back. No head strike or LOC. Patient is unable to tell me exactly when this happened. She says it was ___ or ___ but does not believe it was 1 week ago. Patient's PCP called EMS and patient was BIBA for evaluation. In the ED, initial vital signs were 98.6, 64, 230/78, 20, 95% RA. Labs were remarkable for Hgb 10.4 (baseline), Cr 2.2 (baseline), troponin 0.29 (baseline), BNP 20,384, and lactate 0.9. Imaging was remarkable for CT ___ with burst fracture of L4 vertebral body with 6 mm of retropulsion. MRI ___ with no abnormal cord signal and mild canal narrowing. Ortho Spine consulted. They recommended against MRI. The recommended that TLSO brace to be worn out of bed. No need for cervical or log roll precautions. Patient was given gentle IVF and hydralazine with some improvement in hypertension. She was admitted to Medicine. On transfer, vital signs were 98, 60, 197/80, 22, 95% RA. On the floor, patient reports that she is feeling well. She denies back pain, although she did have some mild lumbar back pain earlier. Patient denies fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, and urinary symptoms. She reports that her lower extremity strength and sensation feels at baseline. She denies fecal or urinary incontinence and saddle anesthesia. Review of Systems: As per HPI Past Medical History: - Hypertension - Hyperlipidemia - Type 2 diabetes. Diet-controlled. - Diastolic CHF - CKD stage V with baseline Cr 1.8-2.2 - OSA on CPAP - Osteoporosis - Osteoarthritis - Incidental syrinx at C1-T10 - Gout - Hypercalcemia NOS Social History: ___ Family History: Father died of cerebral hemorrhage. Mother died of PNA. Son with glomerulonephritis. Physical Exam: Admission GENERAL: Elderly female in no distress HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear NECK: Supple, JVP at angle of mandible CARDIAC: RRR, nl S1/S2, SEM at RUSB radiating to carotids, crescendo/decrescendo murmur at apex LUNG: Limited exam, faint crackles at bases bilaterally ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: 2+ pitting edema bilaterally NEURO: AAOx2 (thinks it is ___ CN II-XII intact, upper extremity strength intact, able to lift both legs off bed against resistance, ___ plantarflexion and dorsiflexion bilaterally, sensation intact throughout, DTR's 1+ bilaterally SKIN: Warm and dry, no concerning lesions Discharge GENERAL: Elderly female in no distress HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear NECK: Supple, JVP 9cm CARDIAC: RRR, nl S1/S2, SEM at RUSB radiating to carotids, crescendo/decrescendo murmur at apex LUNG: Limited exam, faint crackles at bases bilaterally ABDOMEN: Soft, NTND, normoactive bowel sounds EXTREMITIES: 2+ pitting edema bilaterally NEURO: AAOx2 CN II-XII intact, upper extremity strength intact, able to lift both legs off bed against resistance, ___ plantarflexion and dorsiflexion bilaterally, sensation intact throughout, DTR's 1+ bilaterally SKIN: Warm and dry, no concerning lesions Pertinent Results: Admission ___ 05:40PM BLOOD WBC-8.3 RBC-3.56* Hgb-10.4* Hct-33.3* MCV-94 MCH-29.3 MCHC-31.3 RDW-17.0* Plt ___ ___ 05:40PM BLOOD Neuts-77.7* Lymphs-14.3* Monos-5.9 Eos-1.9 Baso-0.3 ___ 05:40PM BLOOD Glucose-131* UreaN-42* Creat-2.2* Na-144 K-4.5 Cl-111* HCO3-24 AnGap-14 ___ 05:40PM BLOOD CK(CPK)-219* ___ 05:40PM BLOOD CK-MB-4 cTropnT-0.29* ___ ___ 07:27AM BLOOD Albumin-3.1* Calcium-10.4* Phos-3.3 Mg-2.0 ___ 11:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:30PM URINE Blood-SM Nitrite-NEG Protein-600 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 11:30PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 Discharge ___ 07:00AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.2* Hct-27.8* MCV-92 MCH-30.4 MCHC-33.0 RDW-17.7* Plt ___ ___ 03:00PM BLOOD Glucose-132* UreaN-76* Creat-2.7* Na-142 K-3.8 Cl-108 HCO3-24 AnGap-14 Pertinent ___ 05:40PM BLOOD Glucose-131* UreaN-42* Creat-2.2* Na-144 K-4.5 Cl-111* HCO3-24 AnGap-14 ___ 07:29AM BLOOD UreaN-64* Creat-2.3* Na-146* K-4.3 Cl-114* HCO3-24 AnGap-12 ___ 07:32AM BLOOD Glucose-104* UreaN-67* Creat-2.4* Na-142 K-3.9 Cl-110* HCO3-21* AnGap-15 ___ 06:50AM BLOOD Glucose-110* UreaN-68* Creat-2.5* Na-144 K-3.5 Cl-109* HCO3-26 AnGap-13 ___ 06:45AM BLOOD Glucose-109* UreaN-76* Creat-2.7* Na-140 K-4.0 Cl-107 HCO3-26 AnGap-11 ___ 03:00PM BLOOD Glucose-132* UreaN-76* Creat-2.7* Na-142 K-3.8 Cl-108 HCO3-24 AnGap-14 ___ 07:29AM BLOOD RENIN-0.74 ___ 07:29AM BLOOD ALDOSTERONE-PND Renal U/S ___ IMPRESSION: 1. No evidence of tardus parvus waveforms. 2. Patent bilateral main renal veins. 3. Multiple bilateral renal cysts which appear simple ___ CT head w/o contrast IMPRESSION: 1. No signs of intracranial bleed. 2. Involutional changes and probable chronic small vessel ischemic disease. MR ___ ___ IMPRESSION: 1. Study is degraded by motion, especially on axial images. 2. Please note that the numbering of vertebral body levels in this study designates the lowest rib bearing vertebral body level as the T12 level, which differs from the ___ CT lumbar spine CT (where this level is designated L1, and in which the compression fracture of concern is designated the L4 level). Please note that prior to any surgical intervention, appropriate levels should be established. 3. Transitional lumbar spine anatomy with partial sacralization of L5 vertebral body. 4. Compression fracture of L3 with 6 mm retropulsion of the superior endplate resulting in moderate to severe spinal canal narrowing at L2-3 in combination with additional degenerative changes. 5. Additional multilevel multifactorial lumbar spondylosis as described above. 6. Partially visualized nonspecific at least partially cystic bilateral renal lesions as described. While findings may represent renal cysts, other etiologies are not excluded on the basis of this noncontrast examination. Recommend clinical correlation. If clinically indicated, further evaluation may be obtained via renal ultrasound. CT ___ IMPRESSION: 1. Unstable 2 -column burst fracture of the L4 vertebral body with 6 mm of retropulsion. Moderate multilevel degenerative changes. 2. Multi-cystic right kidney, incompletely imaged. When compared to CT torso of ___, these are unchanged. CT head ___ IMPRESSION: No acute intracranial abnormality. CT T-spine ___ IMPRESSION: 1. No fracture traumatic or malalignment of the thoracic spine. 2. 7 mm peripheral nodular density in the right lower lobe, possibly scarring from prior infection. Followup chest CT is recommended in three months to ensure stability. 3. Trace to small nonhemorrhagic bilateral pleural effusions. 4. Moderate cardiomegaly and trace pericardial effusion. CT c-spine ___ IMPRESSION: 1. No acute fracture or traumatic malalignment. 2. Mild to moderate multilevel degenerative disc disease. Brief Hospital Course: ___ yo F with multiple medical problems here with BLE weakness found to be due to an L4 vertebral fracture. ACTIVE ISSUES # Hypertensive emergency/urgency : Blood pressure 208/70 on admission without end-organ damage. Per review of OMR, patient is typically fairly hypertensive (many SBP's in 180's). SBP in 200-210s earlier on admission. ___ AM, had one episode of nausea/voming concerning for end-organ damage from hypertensive emergency. Had CT head w/o contrast done for eval of bleed given nausea/vomiting. CT unremarkable. Last admission, had similar episodes of hypertensive emergency. SBP was better controlled with labetalol. Labetalol switched to carvedilol in the past given concern for bradycardia at cards f/u. Pt was started on amlodpine 5mg daily and home clonidine increased from 0.2 to 0.3/day and valsartan from 80mg BID to ___ BID. Switched carvedilol 25mg BID to labetalol, but switched back given bradycardia to upper ___, low ___. No sign of RAS on U/S. Renin ___ sent, pending on discharge. SBPs improved with discharge SBPs 130-160. # Spinal fracture: L4 vertebral burst fracture. Most likely traumatic from fall out of bed. Patient seen by Ortho Spine in ED. They recommended LSO while OOB and follow-up in clinic. Got LSO brace on ___. Evaluated by ___ and discharged to rehab. Advised to follow up with orthospine in 1 week. # acute on chronic kidney injury: increase from baseline of 2.2 to 2.7, most likely pre-renal in the setting of poor po intake. Home lasix held on discharge. Will need daily BMP check and lasix should be restarted when Cr downtrending or patient develops signs of volume overload. CHRONIC ISSUES # Hyperlipidemia: Continued statin. # Type 2 diabetes: Diet-controlled. sliding scale as needed. # Chronic Diastolic CHF: BNP elevated but, but most likely in the setting of renal failure. No evidence of volume overload. given ___, lasixx held on discharge. # Gout: Continued allopurinol. # OSA: on CPAP at home, continued on CPAP =========================== TRANSITIONAL ISSUES =========================== -LSO brace while OOB until f/u in ___ clinic. -Medication change: Increased dose of valsartan, clonidine and started amlodipine with good BP control. -Cr increased on day of discharge to 2.7 from 2.5(baseline around 2.2). Home lasix discontinued. Please check electrolytes daily, and encourage PO intake. Restart lasix when creatinine downtending or any signs of volume overload. -7 mm peripheral nodular density in the right lower lobe, possibly scarring from prior infection. Followup chest CT is recommended in three months to ensure stability -Aldosterone pending result at discharge. CODE: FULL Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QMON 3. Ferrous GLUCONATE 324 mg PO DAILY 4. Gabapentin 300 mg PO DAILY 5. HydrALAzine 50 mg PO TID 6. Simvastatin 40 mg PO DAILY 7. Sodium Bicarbonate 650 mg PO BID 8. Isosorbide Dinitrate SA 40 mg PO Q8H 9. Valsartan 80 mg PO BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion 11. Furosemide 20 mg PO BID 12. Aspirin 81 mg PO DAILY 13. Carvedilol 25 mg PO BID 14. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Carvedilol 25 mg PO BID 4. Ferrous GLUCONATE 324 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion 6. Gabapentin 300 mg PO DAILY 7. HydrALAzine 50 mg PO TID 8. Isosorbide Dinitrate 40 mg PO Q8H 9. Simvastatin 20 mg PO DAILY 10. Sodium Bicarbonate 650 mg PO BID 11. Valsartan 160 mg PO BID 12. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 13. Amlodipine 5 mg PO DAILY 14. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON 15. Acetaminophen 1000 mg PO Q8H pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary L4 burst fracture Hypertensive Emergency/Urgency Hypernatremia Acute on chronic kidney injury Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane) with LSO BRACE. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear ___, ___ were admitted after falling at home. ___ were found to have a fracture(a break in the bone) of one of your back bones. ___ were seen by the bone surgeons and were given a brace(support structure) to wear when out of bed. ___ were seen by our physical therapy team who recommended continuing your care at a rehabilitation facility. Your blood pressure was very elevated and we increased the dose of your home valsartan/clonidine and started ___ on amlodipine. Given some signs of kidney injury, home lasix(water pill) held on discharge to rehab. The providers at the rehabilitation facility will restart the water pill when appropriate. Sincerely, ___ Care Team Followup Instructions: ___
19831143-DS-17	19,831,143	21,450,539	DS	17	2177-08-13 00:00:00	2177-08-14 09:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin Attending: ___. Chief Complaint: Fevers, Chills, Cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___, ___ asthmatic bronchitis/COPD presenting with fevers, chills and cough productive of green thick mucus x 5 days. She states that ~5 days ago she started having a sore throat and fatigue. This was followed by sweats and chills followed by cough. She started using Mucinex and then began expectorate thick green mucous. She also increased the frequency at which she used her inhalers up to a max of 20 times yesterday because it was the only thing she knew to do to help her breathing. Last night she woke up w/dyspnea and gasping. She also complains of worsening right sided chest and rib pain that was brought on by her frequent coughing. The pain is sharp in nature and radiates around to right scapula and mid back. She denies any pleuritic chest pain. In the ED, initial vs were: T 98.9 HR 94 BP 139/62 RR 24 O2Sat 100% Non-Rebreather. Labs were remarkable for WBC 8.4 w/65%PMNs, HCT 38.7, Cr 0.6, normal electrolytes, Lactate 1.4. Urinalysis showed trace leuks, no bacteria, <1 WBC, <1 EPI. EKG showed NSR with isolated ST dep in III unchanged from prior. Influenza DFA was negative, Blood cultures were also drawn. Patient was given Duonebs x 3, Tamiflu x 1, Morphine x 2, Ctx 1g, Azithromycin, and Methylpred 125. Vitals on Transfer: T 99.2, HR 99 BP 114/62 RR 18 O2Sat 95%RA On the floor, vs were: T98.7 P96 BP 137/44 R 22 O2 sat99%RA. She states that her companion of ___ years passed away this week and she is mourning his loss, but glad that he is in a safer place. On review of records, she had a flu shot at ___ ___. Past Medical History: Asthmatic Bronchitis Tobacco abuse Social History: ___ Family History: Her family history is notable for her mother who had diabetes and her son who has allergies. Physical Exam: ADMISSION EXAM: Vitals: T:98.7 BP:137/44 P:96 R:22 O2:99%RA General: Thin woman, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bilateral expiratory wheezing scattered throughout lung fields CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes, lesions Neuro: CNII-XII grossly intact, strength and sensation grossly normal, gait normal BACK: small lipoma over left ischium DISCHARGE EXAM: Vitals: T:97.4 BP:116/65 P:97 R:18 O2:96%RA General: Thin woman, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bilateral expiratory wheezing scattered throughout lung fields CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes, lesions Neuro: CNII-XII grossly intact, strength and sensation grossly normal, gait normal Pertinent Results: ADMISSION LABS: ___ 11:19AM BLOOD WBC-8.4# RBC-4.12* Hgb-13.0 Hct-38.7 MCV-94 MCH-31.5 MCHC-33.5 RDW-14.4 Plt ___ ___ 11:19AM BLOOD Plt ___ ___ 11:19AM BLOOD Glucose-126* UreaN-6 Creat-0.6 Na-142 K-3.4 Cl-100 HCO3-31 AnGap-14 ___ 06:30AM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1 ___ 11:30AM BLOOD Lactate-1.4 CXR ___: FINDINGS: The cardiac silhouette size is normal. The aorta is mildly tortuous with calcifications is noted at the aortic knob. Calcified granulomas are re- demonstrated in the left upper lobe medially. The pulmonary vascularity is normal and the hilar contours are unremarkable. Lungs are hyperinflated compatible with emphysema as seen previously. Ill-defined nodular and branching opacities are noted within the left lung base, which could reflect bronchial inflammation or infection or infection as seen on the prior chest CT. The. No pleural effusion or pneumothorax is present. There are no acute osseous abnormalities. IMPRESSION: Findings suggestive of an inflammatory or infectious process involving the airways within the left lung base. ___. ___ ___ LABS: ___ 06:30AM BLOOD WBC-11.2* RBC-4.01* Hgb-12.5 Hct-38.2 MCV-95 MCH-31.2 MCHC-32.7 RDW-14.2 Plt ___ ___ 06:30AM BLOOD Glucose-132* UreaN-13 Creat-0.6 Na-142 K-3.7 Cl-102 HCO3-22 AnGap-22* Brief Hospital Course: ASSESSMENT AND PLAN: Ms. ___ is a ___, PMH Asthma and COPD presenting with fevers, chills and cough productive of green thick mucus x 5 days. ACUTE ISSUES: # COPD/PNA: Patient presents with complaints of fevers, chills and cough with increased sputum production concerning for COPD exacerbation. Her exacerbation was likely triggered by viral vs. bacterial PNA given that she has been experiencing fevers and chills as well as the LLL opacity/inflammation seen on her CXR. Favor viral given onset of sxs with sore throat and fatigue. Given that her influenza DFA was negative and she has no recent hospitalizations would favor treated for CAP along with exacerbation of her COPD. Will continue Azithromycin for COPD/PNA given that may help more with the inflammatory of exacerbation. She was also continued on standing Duonebs. She remained stable overnight and was satting well on RA on day of discharge. She was d/c home with Prednisone taper until seen by PCP who can determine the need for continued slow taper. She will also complete ad 5 day course of Azithromycin. Her outpatient Pulmonologist was consulted who agreed with the plan. Social work and case management provided assistance with helping pt get a nebulizer and humidifier in her home. # Chest Pain: patient also report CP associated with her worsening cough. This is likely musculoskeletal. She has takes ASA daily and has a significant smoking hx, but has no known cardiac history, diabetes, hyperlipidemia, or known family hx. Also reassuring is that her CP is right sided, in addition, her EKG was unchanged from prior in OMR. She was continued on home Percocet for low back pain and tylenol. On day of discharge her CP had greatly improved. # Tobacco use: patient has been attempting to decrease her cigarette consumption. She got in the prayer line at church and was able to cut back. Currently she takes two puffs of a cigarette and throws it away. She does this on about ~3 cigarettes per day. She was placed on nicotine patch while in hospital, but patient preferred to get electronic cigarettes upon discharge. TRANSITIONAL ISSUES: - Pt d/c home with new ___ services to help with teaching technique on new Nebulizer. Also to help use humidifier to decrease environmental dust/dryness in the home. - Pt would benefit from additional teaching on proper Inhaler use - Pt complained of buttock pain, not associated with movement, but TTP, no obvious areas of flutuance were noted on exam. Should be monitored upon follow-up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 100 mcg PO DAILY 2. Symbicort NF (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation 2 PUFFS BID 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, sob 4. Ipratropium Bromide MDI 2 PUFF IH QID 5. Aspirin EC 81 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Cyanocobalamin 100 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H RX albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB IH every 6 hours Disp #2 Bottle Refills:0 5. Azithromycin 250 mg PO Q24H RX azithromycin 250 mg 1 tablet(s) by mouth daily Disp #3 Tablet Refills:0 6. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN cough RX dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth every 6 hours Disp #1 Bottle Refills:0 7. Ipratropium Bromide Neb 1 NEB IH Q6H RX ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb IH every 6 hours Disp #2 Bottle Refills:0 8. PredniSONE 40 mg PO DAILY RX prednisone 10 mg 1 tablet(s) by mouth daily, as below Disp #27 Tablet Refills:0 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, sob 10. Ipratropium Bromide MDI 2 PUFF IH QID 11. Symbicort NF* (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION 2 PUFFS BID 12. Humidifer Please dispense 1 room air humidifier. 13. nebulizer & compressor NF 1 Nebulizer machine Miscellaneous daily use as needed RX nebulizer & compressor For Asthmatic Bronchitis 493.2 use daily as needed Disp #1 Unit Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Asthmatic Bronchitis Exacerbation Secondary Diagnosis: Viral respiratory infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, you were admitted to the ___ ___ with complaints of fevers, chills and cough. You were found to be having an exacerbation of your asthma/bronchitis which was likely due to a viral illness. However, your flu test was negative. You will be treated for five days with prednisone and with antibiotics. It is important that you follow up with your Primary Care Doctor and with your ___. Please see below for your follow-up appointments. It was a pleasure caring for you and we wish you a speedy recovery! Followup Instructions: ___
19831143-DS-18	19,831,143	27,576,865	DS	18	2177-10-15 00:00:00	2177-10-15 17:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin Attending: ___. Chief Complaint: Shortness of breath Reason for MICU transfer: Respiratory distress requiring intubation Major Surgical or Invasive Procedure: Intubation and mechanical ventilation, bronchoscopy History of Present Illness: ___ with history of asthma and COPD (not on O2) with recent hospitalization for COPD exacerbation, presents with one day of severe shortness of breath and grunting. She has also had two days of cough productive of brownish sputum. She states that she ran out of her inhaler medications today. She also endorses chest pain per EMS, relieved by 2 nitroglycerin. She was placed on a non-rebreather and transported by EMS to the ___ ED. In the ED, patient is tachypneic with expiratory grunting. Initial vitals: HR 119 BP 168/93 RR 45 O2 sat 100%. She received nebulizers and was placed on non-rebreather, given IV solumedrol, IV azithromycin 500mg. CXR showed hyperinflated lungs but no evidence of consolidations. VBG: ___. Troponin < 0.01. EKG with prominent p waves and rightward axis, but no ST changes. Vitals on transfer T: 97.9 P: 128 BP: 149/65 R: 29 O2 sat: 97%. On arrival to the MICU, initial vitals: T: 99.5 BP: 130/106 P: 117 R: 26 O2: 95% on 3L. She states that her breathing is better. She complains of chest and rib pain worse with cough and deep breathing. She complains of chronic ankle, back, and neck pain. Denies hemoptysis, recent vomiting or loss of consciousness. Denies diarrhea or fevers, but has had chills. She has been smoking ___ pack per day and drinking "nips" of alcohol daily since ___. Review of systems: (+) Per HPI, +chills, weight loss, productive cough (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies myalgias. Denies rashes or skin changes. Past Medical History: # Asthmatic bronchitis. # ___ abuse. # History of acid reflux. # Back & hip pain on narcotics Social History: ___ Family History: Mother: diabetes Son: allergies Physical Exam: Admission Physical Exam: Vitals: T: 99.5 BP: 130/106 P: 117 R: 26 O2: 95% on 3L General: Cachectic, alert, oriented, no acute distress, able to speak in complete sentences. HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Mild diffuse expiratory wheezes, tachypneic, some use of accessory muscles Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge physical exam: VS: T98.1, BP 115/62, HR 92, RR 24, 96%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decent airmovement bilaterally, prolonged expiratory phase, diffuse expiratory wheezes CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Thin, Warm, well perfused, 2+ pulses, no edema Skin: dry, no rashes Pertinent Results: ADMISSION ___ 03:30PM BLOOD WBC-4.5# RBC-4.80 Hgb-15.3 Hct-46.3 MCV-97 MCH-31.9 MCHC-33.0 RDW-15.3 Plt ___ ___ 03:30PM BLOOD Glucose-116* UreaN-9 Creat-0.7 Na-135 K-5.1 Cl-100 HCO3-22 AnGap-18 ___ 02:20AM BLOOD Calcium-10.1 Phos-2.6* Mg-2.0 ___ 03:30PM BLOOD ___ pO2-91 pCO2-49* pH-7.35 calTCO2-28 Base XS-0 ___ 03:30PM BLOOD Lactate-0.7 ___ 02:20AM BLOOD HBsAg-NEGATIVE DISCHARGE LABS: ___ 07:15AM BLOOD WBC-7.8 RBC-4.94 Hgb-15.7 Hct-46.5 MCV-94 MCH-31.7 MCHC-33.7 RDW-14.5 Plt ___ ___ 07:15AM BLOOD Glucose-91 UreaN-17 Creat-0.6 Na-138 K-3.8 Cl-98 HCO3-29 AnGap-15 ___ 07:15AM BLOOD Calcium-9.7 Phos-3.2 Mg-2.0 ___ bronchial washings Bronchial lavage: NEGATIVE FOR MALIGNANT CELLS. ___ CTPA IMPRESSION: 1. No pulmonary embolus. 2. Moderate-to-severe centrilobular emphysema. 3. Findings again indicative of likely prior granulomatous disease. 4. Support catheters and tubes in proper position. 5. Multiple bilateral thyroid nodules. If no prior ultrasound examination of the thyroid has been performed recommend follow up ultrasound study for further evaluation. ___ CXR A right upper lobe nodule overlying the ___ posterior rib was seen on the prior CT and consistent with an intrapulmonary lymph node. Again there is diffuse emphysema with overexpansion of the lungs. No pleural effusion or pneumothorax. No acute osseous abnormalities. The lungs are clear of focal consolidations, but ill defined bibasilar opacities are present which may relate to chronic changes or overlying soft tissue. Infection or aspiration is not excluded. PA and lateral views may be helpful. ___ TTE The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. MICRO: ___ 6:48 pm Rapid Respiratory Viral Screen & Culture LEFT LUNG BRONCHIAL WASH. PREVIOUSLY LOGGED IN AS RIGHT MIDDLE LOBE.. SPECIMEN TYPE CHANGED, NOTIFIED TO ___ (___) ON ___. FINAL REPORT ___ Respiratory Viral Culture (Final ___: TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final ___: Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. Respiratory Virus Identification (Final ___: Reported to and read back by ___ ___ 11:44AM. POSITIVE FOR PARAINFLUENZA TYPE 3. Viral antigen identified by immunofluorescence. __________________________________________________________ ___ 6:48 pm BRONCHOALVEOLAR LAVAGE LEFT LUNG BRONCHIAL WASH. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. ___. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ___: Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. __________________________________________________________ ___ 2:24 am IMMUNOLOGY CHEM # ___ ___. FINAL REPORT ___ HCV VIRAL LOAD (Final ___: HCV-RNA NOT DETECTED. Performed using the Cobas Ampliprep / Cobas Taqman HCV Test. Linear range of quantification: 43 IU/mL - 69 million IU/mL. Limit of detection: 18 IU/mL. Rare instances of underquantification of HCV genotype 4 samples by Roche COBAS Ampliprep/COBAS TaqMan HCV test method used in our laboratory may occur, generally in the range of 10 to 100 fold underquantitation. If your patient has HCV genotype 4 virus and if clinically appropriate, please contact the molecular diagnostics laboratory (___) so that results can be confirmed by an alternate methodology. __________________________________________________________ ___ 9:17 am SPUTUM Source: Expectorated. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. __________________________________________________________ ___ 6:36 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 3:35 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 5:40 pm BLOOD CULTURE #2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: ___ with history of asthma and COPD (not on O2) with recent hospitalization for COPD exacerbation, presents with one day of severe shortness of breath and grunting, admitted to the MICU for respiratory distress and tachycardia, found to have parainfluenza virus. # COPD/asthma exacerbation/respiratory failure: Patient has known COPD with a component of reversibility consistent with asthma. This exacerbation may have been triggered by a combination of viral or bacterial respiratory illness, smoking, medication non-adherence. Patient presented with respiratory distress and grunting not responding to frequent nebulizers and IV solumedrol. She was placed on BIPAP but continued to show increased work of breathing and signs of respiratory fatigue, and was intubated on ___. She was extubated on ___, but re-intubated later that afternoon for respiratory distress not improving with BIPAP. She was started on azithromycin on ___, then changed to levofloxacin on ___ with concern for resistant organisms given the severity of her COPD exacerbation and rapid clinical deterioration. She is to complete a 7 day course of levofloxacin, ending ___ for community-acquired pneumonia. In terms of other possible etiologies for her respiratory failure, a CTA ruled out pulmonary embolus. Cardiac echo revealed normal ejection fraction, but mild mitral regurgitation. Bronchoscopy was performed on ___ which was notable for purulent material visualized on the left. Left lung bronchial washings were positive for parainfluenza virus type 3 which was thought to be the cause of the patient's prolonged course of respiratory distress and re-intubation. The patient was again extubated on ___ with improved respiratory status and only occasional wheezes. She was satting well on room air with ambulatory sats 94-97% on room air. Discharged on PRN albuterol, ipratropium, symbicort and prenisone taper, with pulmonologist follow up in two weeks. # Chest pain/jaw pain: EKG similar to baseline and repeat EKG without ischemic changes. Cardiac enzymes were negative x 2. Pain only seems to come when pt is in respiratory distress, so may be due to tachypnea, anxiety. Cardiac etiology was ruled out as above. She had no further chest pain after leaving ICU. # ___ abuse: Maintained on nicotine patch and encouraged smoking cessation. # Chronic pain: Maintained on oxycodone while in house (takes percocet at home). # ETOH: Patient reports increased alcohol consumption since the death of her close friend in ___. Maintained on CIWA scale q6h, did not score. Social work was consulted. # Healthcare maintenance: Continued calcium/vitamin D Transition of care issues: - Recommend ultrasound follow-up of thyroid nodules incidentally found on CTA - Encourage continued smoking cessation - Prednisone taper to continue until she sees Dr. ___ - ___ stay at rehab less than 30 days Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin EC 81 mg PO DAILY 2. Cyanocobalamin 100 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath or wheezing 5. Symbicort NF (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation BID 2 puffs twice daily 6. Ipratropium Bromide MDI 2 PUFF IH QID 2 puffs(s) inhaled every six (6) hours 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Frequency is Unknown hip, back pain 8. Calcium 600 + D(3) NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral BID Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Cyanocobalamin 100 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB or wheeze 6. Nicotine Patch 14 mg TD DAILY 7. Polyethylene Glycol 17 g PO DAILY 8. Thiamine 100 mg PO DAILY 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath or wheezing 10. Calcium 600 + D(3) NF (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral BID 11. Ipratropium Bromide MDI 2 PUFF IH QID 12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN hip, back pain RX oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every 6 (six) hours Disp #60 Tablet Refills:0 13. Symbicort NF* (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation BID 14. Docusate Sodium 100 mg PO BID 15. PredniSONE 30 mg PO DAILY Duration: 4 Days 30mg/day from ___ to ___ Tapered dose - DOWN 16. PredniSONE 20 mg PO DAILY Duration: 4 Days 20mg/day from ___ to ___ Tapered dose - DOWN 17. PredniSONE 10 mg PO DAILY 10mg/day from ___ until you see Dr. ___ ___ dose - DOWN Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: chronic obstructive pulmonary disease, bacterial pneumonia organism unspecified, parainfluenza infection Secondary: alcohol abuse, ___ abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure caring for you during your hospitalization at ___. You were admitted for shortness of breath and were found to have a COPD exacerbation, probably triggered by infection with a virus called "parainfluenza". You spent time in the intensive care unit and required intubation for a few days because of sever difficulty breathing. You were also treated for a possible pneumonia with a 7 day course of antibiotics. Please continue taking prednisone in decreasing doses as outlined in your medication list until you see Dr. ___ in clinic. Congratulations on quitting smoking! This is a very important step in stopping progression of your chronic obstructive pulmonary disease. Followup Instructions: ___
19831368-DS-2	19,831,368	20,556,494	DS	2	2140-05-12 00:00:00	2140-05-12 16:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/o significant past medical and surgical history p/w 1 day of abdominal pain found to have SBO on CT. He notes that the pain started yesterday, it was mainly in the periumbilical and epigastric region, crampy worsening with food. He also felt bloated. He forced himself to vomit and felt slightly better. The pain persisted until today which made him visit to the ED for evaluation. In ED he had a normal EKG and normal labs including LFTs and lipase. CT abdomen/pelvis was obtained which showed small bowel obstruction with dilated proximal small bowel loops. On exam he was not complaining of pain after getting Morphine 5 mg IV, his abdomen was soft and not distended, non tender. Past Medical History: none Social History: ___ Family History: none Physical Exam: Physical Exam:Up[on admission Vitals:98.3 98 78 113/78 18 100%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, tender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused Physical Exam:Upon discharge Vitals:Stable GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 06:05AM GLUCOSE-108* UREA N-10 CREAT-1.0 SODIUM-139 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11 ___ 06:05AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.3 ___ 06:05AM PLT COUNT-210 ___ 04:00PM GLUCOSE-110* UREA N-11 CREAT-1.0 SODIUM-139 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 ___ 04:00PM estGFR-Using this ___ 04:00PM ALT(SGPT)-29 AST(SGOT)-27 ALK PHOS-63 TOT BILI-0.5 ___ 04:00PM LIPASE-46 ___ 04:00PM ALBUMIN-4.8 ___ 04:00PM WBC-10.1 RBC-5.54 HGB-16.6 HCT-48.7 MCV-88 MCH-30.0 MCHC-34.2 RDW-13.7 ___ 04:00PM NEUTS-74.1* ___ MONOS-4.1 EOS-0.6 BASOS-0.4 ___ 04:00PM PLT COUNT-234 ___ 04:00PM ___ PTT-32.5 ___ Brief Hospital Course: The patient presented to the hospital on ___ complaining of abdominal pain. Pt was transferred to the floor for conservative treatment. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO and on ___ his diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital complaining of abdominal pain on ___. You were found to have a small bowel obstruction and were admitted to the floor under the care of Acute Care Services for conservative treatment. You are now feeling better and you are ready to go home. Please adhere to the following instructions for discharge. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
19831776-DS-17	19,831,776	23,968,790	DS	17	2150-11-20 00:00:00	2150-12-02 15:07:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Compazine / Demerol / Phenobarbital / Magnevist / Gadolinium-Containing Agents / Dilaudid (PF) / Tegaderm Attending: ___. Chief Complaint: nausea/vomiting/abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ w ___ dysmotility, obstructive rectocele and hx SBO requiring LOA x 2 presenting with nausea, vomiting, abdominal pain x 4 days. Patient has long history of dysmotility with extensive, ongoing GI workup including planned ___ marker study in coming weeks; and bowel regimen dependence including routine usage of high dose miralax and glycerin suppositories. Also w known obstructive rectocele seen on defecography currently being evaluated in joint fashion by Gyn (___) and Colorectal (___). Patient was in usual state of health until ___ ___ when she awoke from sleep with increased abdominal distention and sharp abdominal pains which resolved with flatus that AM. Over following days patient had return of pain with accompanying nausea, anorexia and increasingly infrequent passage of flatus/stool. Pain described as moderate to severe, located in epigastrium (L>R) and constant dullness w sharp exacerbations. In last ___ days has attempted cleanout with 68g miralax x 2 and multiple glycerin suppositories without significant effect. States she has passed minimal mucus but is without substantial BM in ___ days. Has had several ___ episodes of non-bloody emesis in last 48 hours. Last flatus was ___ and persistent pain prompted visit to ___ ED for evaluation. Surgical consultation sought for eval of SBO vs constipation. On surgical eval patient states symptoms as above. Given fleet's enemas x 2 in ED without effect. Despite chronic issues patient reports she is maintaining her weight. Denies fever, chills, chest pain, shortness of breath, dysuria. Of note, patient recently underwent GYN procedure ___ (EUA/LEEP/D&C/endometrial polypectomy) though reports uneventful recovery from this. Also, last c-scope was ___ at ___ (reportedly normal) and last EGD ___ notable for Schatzki's ring. Past Medical History: PMH: Chronic abdominal pain, Colonic dysmotility, Obstructive rectocele, Hx anal fissure s/p lateral sphincterotomy, Hx gallstone pancreatitis s/p lap CCY, L breast mucinous adenoCA s/p breast conserving surgery, XRT now on hormone therapy (XRT completed ___ path: T1bN0, ER/PR POS, Her2neu NEG), R breast LCIS, Hx DVT in setting OCPs previously on coumadin (___), Hx nephrolithiasis s/p L ureteral stent placement/removal (___), Hx hyperthyroidism (resolved-___), Hx BCC abdominal wall s/p excision (___) PSH: L ovarian torsion s/p excision (___), R salpingectomy for ectopic pregnancy (___), R oophorectomy for tubo-ovarian abscess (___), Cystoscopy/L ureteral stent for nephrolithiasis (___), B/L cataracts w lens implants (___), Lap CCY w IOC for recurrent GB pancreatitis (___), L median nerve decompression for carpal tunnel syndrome (___), R lumpectomy (___), R median nerve decompression for carpal tunnel syndrome (___), Lap LOA (___), Ex lap/LOA/Seprafilm placement/Excision abd wall BCC (___), L lateral internal sphincterotomy w Botox injection for recurrent anal fissure (___), L lumpectomy (___), L sentinel node bx (___), EUA/LEEP/D&C/Polypectomy for cervical stenosis, endometrial thickening, rectocele (___) Social History: ___ Family History: Father deceased from prostate cancer, also had celiac and colon polyps. Mother deceased from CVD at old age, had diverticulitis and diabetes. Physical Exam: VS: 96.9 94 121/80 18 100% GEN: WD, WN obese F in NAD HEENT: NCAT, EOMI, anicteric CV: RRR PULM: CTA B/L, no respiratory distress ABD: soft, +tender to moderate palpation in epigastrium (L>R), minimally distended w tympany in epigastrium, no mass, no hernia, well healed midline laparotomy incision RECTAL: +perianal skin tags, anterior fissure, normal tone, no masses, no gross blood, no stool in rectal vault for guaiac EXT: WWP, no CCE, no tenderness NEURO: A&Ox3, no focal neurologic deficits Changes at time of discharge: Abd: soft, non-tender, nondistended Pertinent Results: ___ 11:55AM BLOOD Glucose-104* UreaN-11 Creat-0.8 Na-140 K-4.1 Cl-105 HCO3-24 AnGap-15 ___ 11:55AM BLOOD ___ PTT-28.9 ___ ___ 11:55AM BLOOD ALT-24 AST-24 AlkPhos-62 TotBili-0.5 ___ 05:35AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.1 ___ 11:55AM BLOOD WBC-4.9 RBC-4.60 Hgb-14.4 Hct-42.5 MCV-93 MCH-31.3 MCHC-33.8 RDW-13.0 Plt ___ CT Scan ___ IMPRESSION: 1. No acute intra-abdominal process is detected. 2. Scattered sigmoid colon diverticula without signs of diverticulitis. 4. Fibroid uterus. Brief Hospital Course: Patient was seen in the emergency department on ___. She received 2 enema's in the ED for large amounts of stool seen on KUB. She was admitted to the ___ surgical service under Dr. ___ concern for possible small bowel obstruction. On HD 2 the patient was experiencing frequent waterly stools, but her nausea had improved. Patient started on clear liquids. Patient given 2 doses of MOM of continued large amount of stool in colon. Patient reported nausea/abdominal pain after 2nd dose of MOM. KUB showed no evidence of obstuction, just large amount of fluid in colon consistent with gastroenteritis. On HD 3 patient was advanced to regular diet, passing flatus. On HD 4 Patient given 1 dose of toradol for pain, KUB showed no evidence of obstruction. IV infiltrated. On HD 5 a CT scan was performed that showed No acute intra-abdominal process. On HD 6 day of discharge the patient's pain had improved, patient was tolerating a regular diet, ambulating without assistance, voiding without difficulty. Medications on Admission: ketoconazole 2% Topical Cream Apply to face ___ prn rash, anastrozole 1', Calcium 500+D 500 (1,250)-200', lorazepam 0.5 Q6H prn anxiety, alendronate 70 Qweek, EpiPen prn, nifedipine Powder 2% ointment BID prn anal pain, Zovirax 5% Ointment apply affected area BID, Vagifem 10 Vaginal Tab 2x/week, fluticasone 50mcg/Act Nasal Spray prn Discharge Medications: 1. Percocet ___ mg Tablet Sig: ___ Tablets PO every ___ hours as needed for pain. Disp:10 Tablet(s) Refills:0 2. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea: If nausea persists after 2 doses call your doctor or go to the emergency room. Disp:10 Tablet(s) Refills:0 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every ___. 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal BID (2 times a day). 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 6. ketoconazole 2 % Cream Sig: One (1) application Topical twice a day as needed for rash. 7. Zovirax 5 % Ointment Sig: One (1) application Topical twice a day. 8. Vagifem 10 mcg Tablet Sig: One (1) Vaginal 2x per week. 9. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) pen Intramuscular once as needed. 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: ___ MLs PO Q6H (every 6 hours) as needed for constipation. 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Gastroenteritis Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ___ under Dr. ___ on ___ for concern of a possible small bowel obstruction vs constipation/gastroenteritis. You pain, nausea and abdominal distension have improved dramatically and you are now ready to continue recovering at home. Medications: Please resume all of your home medications as prescribed. Pain medication has been prescribed for you. Please take this medication as prescribed. Do not drive while taking narcotic pain medication. Nausea medication has been prescribed for you. Please take this medication as prescribed. Do not take more than 2 doses for the same episode of nausea. Diet: You may resume your regular home diet as tolerated. Activity: You may resume your regular daily activities. Please call Dr. ___ if you experience any of the following: Abdominal pain Abdominal swelling Nausea and vomiting Vomiting blood Difficulty swallowing Diarrhea Constipation Blood in stool Black stool Fever greater than 101 Chills Please call Dr. ___ ___ to schedule a follow up appointment in ___ weeks. Followup Instructions: ___
19831776-DS-18	19,831,776	26,131,263	DS	18	2157-06-04 00:00:00	2157-06-04 11:09:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Demerol / Phenobarbital / Magnevist / Gadolinium-Containing Agents / Dilaudid (PF) / Tegaderm / Iodinated Contrast- Oral and IV Dye / Iodinated Contrast- Oral and IV Dye Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of pelvic floor dysfunction with a large anterior rectocele, IBS, gastric dysmotility, and chronic abdominal pain who presents for evaluation of abdominal pain, nausea, and vomiting since earlier this week with acute worsening over the past day. The patient has a complex gastrointestinal history, outlined in Dr. ___ recent GI note. She has chronic abdominal pain, on a background of a history of multiple abdominal surgeries. She has irritable bowel syndrome, with chronic GI dysmotility. About 1 week ago, she describes a change in her usual symptoms. She has pain in a bandlike distribution across her mid abdomen as well as in the left lower quadrant. It has become progressively intense over the course of this week, and became severe and constant overnight. It has been associated with vomiting and a single episode of nonbloody nonbilious emesis. Chills but no measured fever. No cardiac pulmonary symptoms. No dysuria. She had a small volume loose stool last night. She cannot describe her most recent prior normal bowel movement, stating that she does not have normal bowel movements. Has been discussing MR enterography with Dr. ___, as CT scans have been unrevealing. Past Medical History: PMH: Chronic abdominal pain, Colonic dysmotility, Obstructive rectocele, Hx anal fissure s/p lateral sphincterotomy, Hx gallstone pancreatitis s/p lap CCY, L breast mucinous adenoCA s/p breast conserving surgery, XRT now on hormone therapy (XRT completed ___ path: T1bN0, ER/PR POS, Her2neu NEG), R breast LCIS, Hx DVT in setting OCPs previously on coumadin (1980s), Hx nephrolithiasis s/p L ureteral stent placement/removal (___), Hx hyperthyroidism (resolved-___), Hx BCC abdominal wall s/p excision (___) PSH: L ovarian torsion s/p excision (___), R salpingectomy for ectopic pregnancy (___), R oophorectomy for tubo-ovarian abscess (___), Cystoscopy/L ureteral stent for nephrolithiasis (___), B/L cataracts w lens implants (___), Lap CCY w IOC for recurrent GB pancreatitis (___), L median nerve decompression for carpal tunnel syndrome (___), R lumpectomy (___), R median nerve decompression for carpal tunnel syndrome (___), Lap LOA (___), Ex lap/LOA/Seprafilm placement/Excision abd wall BCC (___), L lateral internal sphincterotomy w Botox injection for recurrent anal fissure (___), L lumpectomy (___), L sentinel node bx (___), EUA/LEEP/D&C/Polypectomy for cervical stenosis, endometrial thickening, rectocele (___) Social History: ___ Family History: Father deceased from prostate cancer, also had celiac and colon polyps. Mother deceased from CVD at old age, had diverticulitis and diabetes. Physical Exam: Admission Exam: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, tender to palpation in LLQ without rebound or guarding. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly symmetric SKIN: No obvious rashes or ulcerations noted on cursory skin exam NEURO: Alert, oriented, face symmetric, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Discharge Exam: GENERAL: Alert, calm, feeling well CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, tender to palpation in LLQ without rebound or guarding. Bowel sounds present. No HSM NEURO: Alert, oriented, face symmetric, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Brief Hospital Course: # Abdominal pain: Pt had MR enterography on nt of admission which was generally unremarkable and not explanatory. Pt subsequently had an ultrasound of her LLQ which documented two ventral herniations, for which surgery was consulted. It was felt that these hernias likely explain her LLQ pain, but not the other symptoms she is having. Per discussion with inpatient and outpt GI (Dr. ___, pt was started on rifaximin for bacterial overgrowth, continued on levsin, and discharged to f/u w/ Dr. ___ Dr. ___ hernia correction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 400 mg PO QHS 2. Hyoscyamine 0.125 mg SL QID 3. Linzess (linaCLOtide) 72 mcg oral Daily before breakfast 4. ValACYclovir 500 mg PO DAILY 5. Polyethylene Glycol 68 g PO DAILY Discharge Medications: 1. Rifaximin 550 mg PO TID RX rifaximin [___] 550 mg 1 tablet(s) by mouth three times a day Disp #42 Tablet Refills:*0 2. Polyethylene Glycol 34 g PO DAILY 3. Gabapentin 400 mg PO QHS 4. Hyoscyamine 0.125 mg SL QID 5. Linzess (linaCLOtide) 72 mcg oral Daily before breakfast 6. ValACYclovir 500 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted for worsening abdominal pain, bloating, and other symptoms. We have added two new medications, and are planning for a surgery to correct your hernia. Now that you are able to go home, we recommend that you follow-up with your GI doctor and our surgical team for hernia repair. We wish you the best with your health. ___ Medicine Followup Instructions: ___
19831776-DS-19	19,831,776	23,178,161	DS	19	2158-03-05 00:00:00	2158-03-06 11:49:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / Phenobarbital / Magnevist / Iodinated Contrast- Oral and IV Dye Attending: ___ Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old F w/ hx of CCY, nephrolithiasis, uterine fibroids, SBO s/p lysis of adhesions, R salpingo-oophrectomy, rectal intussusception, chronic GI dysmotility, pelvic floor dysfunction, and IBS presenting with fevers, nausea, poor appetite, and crampy abdominal pain. She is followed closely by GI as an outpatient. She notes she has been having crampy pain for a week. CT abdomen/pelvis on ___ showed diverticulosis with no obstruction or adhesions. Her abdominal pain has continued to progress with no relief/worsening cramping from hyoscaymine. Last BM yesterday evening with no gas passed since then. Her temperature was 100 at home this morning and she has developed new nausea and poor PO intake. She feels this is similar to her last SBO in ___. In the ED, vitals were notable for absence of fever or hemodynamic instability. Exam showed moderate tenderness in the LLQ with voluntary guarding. Labs notable for normal CBC, coags, LFTs, lipase, chemistries, UA, and lactate. KUB showed a non-obstructive bowel gas pattern. She was given 1L LR, 30 mg IV ketorolac, and 2 mg IV morphine. GI was consulted who recommended sips for comfort, enemas, Miralax, and no plan for procedure. On arrival to the floor, she tells the above story. She still has not passed any gas, but her abdominal pain has subsided a lot. She feels this is not related to food and is likely mechanical. She is amenable to an enema and Miralax to try to have a bowel movement. She denies any current nausea or vomiting. Past Medical History: PMH: Chronic abdominal pain, Colonic dysmotility, Obstructive rectocele, Hx anal fissure s/p lateral sphincterotomy, Hx gallstone pancreatitis s/p lap CCY, L breast mucinous adenoCA s/p breast conserving surgery, XRT now on hormone therapy (XRT completed ___ path: T1bN0, ER/PR POS, Her2neu NEG), R breast LCIS, Hx DVT in setting OCPs previously on coumadin (1980s), Hx nephrolithiasis s/p L ureteral stent placement/removal (___), Hx hyperthyroidism (resolved-1980s), Hx BCC abdominal wall s/p excision (___) PSH: L ovarian torsion s/p excision (___), R salpingectomy for ectopic pregnancy (___), R oophorectomy for tubo-ovarian abscess (___), Cystoscopy/L ureteral stent for nephrolithiasis (___), B/L cataracts w lens implants (___), Lap CCY w IOC for recurrent GB pancreatitis (___), L median nerve decompression for carpal tunnel syndrome (___), R lumpectomy (___), R median nerve decompression for carpal tunnel syndrome (___), Lap LOA (___), Ex lap/LOA/Seprafilm placement/Excision abd wall BCC (___), L lateral internal sphincterotomy w Botox injection for recurrent anal fissure (___), L lumpectomy (___), L sentinel node bx (___), EUA/LEEP/D&C/Polypectomy for cervical stenosis, endometrial thickening, rectocele (___) Social History: ___ Family History: Father deceased from prostate cancer, also had celiac and colon polyps. Mother deceased from CVD at old age, had diverticulitis and diabetes. Physical Exam: ADMISSION EXAM: VITALS: 98.0 PO 115 / 70 L Sitting 74 18 98 Ra GENERAL: Middle aged woman sitting up in bed in no acute distress. Able to move without apparent distress quickly from bed to bathroom and back. Alert and interactive. Non-toxic appearing. HEENT: PER, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Soft. Mild tenderness in LLQ with voluntary guarding and mild rebound tenderness, but able to move around easily in bed with no pain. Normoactive bowel sounds. No masses. Well-healed abdominal scars EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. DISCHARGE EXAM: VITALS: 97.9 AdultAxillary 102 / 61 66 16 99 Ra GENERAL: Middle aged woman sitting up in bed in no acute distress. Able to move without apparent distress quickly from bed to bathroom and back. Alert and interactive. Non-toxic appearing. HEENT: PER, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Soft. Mild tenderness in LLQ with voluntary guarding and mild rebound tenderness, but able to move around easily in bed with no pain. Normoactive bowel sounds. No masses. Well-healed abdominal scars EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Pertinent Results: ADMISSION LABS ============== ___ 06:20PM BLOOD WBC-7.1 RBC-4.32 Hgb-14.3 Hct-42.1 MCV-98 MCH-33.1* MCHC-34.0 RDW-14.2 RDWSD-50.9* Plt ___ ___ 06:20PM BLOOD Neuts-64.0 ___ Monos-8.6 Eos-0.7* Baso-0.7 Im ___ AbsNeut-4.55 AbsLymp-1.82 AbsMono-0.61 AbsEos-0.05 AbsBaso-0.05 ___ 06:20PM BLOOD ___ PTT-26.3 ___ ___ 06:20PM BLOOD Glucose-95 UreaN-7 Creat-0.7 Na-141 K-4.6 Cl-106 HCO3-22 AnGap-13 ___ 06:20PM BLOOD ALT-13 AST-28 AlkPhos-54 TotBili-0.5 ___ 06:20PM BLOOD Lipase-37 ___ 06:20PM BLOOD Albumin-4.3 ___ 06:26PM BLOOD Lactate-1.2 ___ 06:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06:42PM URINE Color-Straw Appear-Clear Sp ___ DISCHARGE LABS ============== ___ 07:25AM BLOOD WBC-4.9 RBC-3.65* Hgb-11.8 Hct-36.8 MCV-101* MCH-32.3* MCHC-32.1 RDW-13.9 RDWSD-51.5* Plt ___ ___ 07:25AM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-141 K-5.9* Cl-107 HCO3-21* AnGap-13 ___ 07:25AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1 MICROBIOLOGY ============ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ======= EXAMINATION: US HERNIA TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the superficial tissues of the left lower quadrant. COMPARISON: None FINDINGS: Transverse and sagittal images of the left lower quadrant were obtained without and with Valsalva. There is visualization of surgical mesh which limits the examination. Within the medial left lower quadrant at the inferior/lateral aspect of the surgical mesh there is a small soft tissue bulge with a small amount of fluid which is located just lateral to the mesh and likely represents a small recurrent reducible hernia. There is a defect incompletely visualized measuring approximately 5 mm and a hernial sac measuring 1.5 x 1.8 cm. IMPRESSION: Limited visualization due to the presence of surgical mesh. There is a small amount of fluid with a likely recurrent reducible hernia at the lateral more inferior aspect of the surgical mesh in the left lower quadrant. Brief Hospital Course: PATIENT SUMMARY: ================ Ms. ___ is a ___ year old F w/ hx of CCY, nephrolithiasis, SBO s/p lysis of adhesions, R salpingo-oophrectomy, rectal intussusception, chronic GI dysmotility, pelvic floor dysfunction, and IBS who presented with nausea, poor appetite, and crampy abdominal pain. In the hospital she was put on a bowel regimen of Miralax and enemas twice a day with the addition of bisacodyl suppositories and her abdominal pain improved. She had an ultrasound which revealed a reducible hernia. ACUTE/ACTIVE ISSUES: ================== # Abdominal pain Her pain was likely multifactorial from her complex abdominal anatomy, IBS, pelvic floor dysfunction, and functional abdominal pain. She also had constipation. A KUB on admission was unremarkable for obstruction and ileus. LLQ US showed a small reducible hernia in the left lower quadrant. Serial exams were non peritoneal. Her pain was managed with Ketorolac 15 mg IV every 8 hours as needed and Tylenol 1 gram every 8 hours as needed. Opiate pain medications were avoided. She was put on a bowel regimen of twice to three times a day miralax and enemas with bisacodyl suppositories and home hyoscamine was held. GI was consulted with no recommendations for intervention during this admission. The pain service was consulted who recommend following up for an outpatient nerve block and titration of pain medications. Of note, nerve block will be most helpful when patient has the most pain. CHRONIC/STABLE ISSUES: ===================== # Insomnia She received Ramelteon every night. # HSV suppression Home valacyclovir was resumed on discharge. # Chronic pain Home 300 mg gabapentin qhs was continued and 100mg in the morning was added TRANSITIONAL ISSUES =================== [] follow up abdominal pain and consider outpatient pain clinic appointment for nerve block when patient has acute pain. Per pain service, diagnostic value of block is best if patient is acutely having pain at time of block. [] Consider uptitrating gabapentin as tolerated. [] follow up for reducible hernia--consider general surgery follow up if patient with persistent pain [] GI follow up for consideration of Prucalopride, donnatal, librax, and IBgard # CODE: Full, presumed # CONTACT: Name of health care proxy: ___ Relationship: Husband Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Polyethylene Glycol 34 g PO DAILY:PRN Constipation - First Line 2. ValACYclovir 500 mg PO Q24H 3. Gabapentin 300 mg PO QHS 4. Hyoscyamine 0.125 mg SL QID 5. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain in rectum 6. NIFEdipine (bulk) 2 % rectal BID prn rectal pain Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Bisacodyl ___AILY:PRN Constipation - Second Line RX bisacodyl 10 mg 1 tablet rectally once a day Disp #15 Suppository Refills:0 3. Gabapentin 100 mg PO QAM RX gabapentin 100 mg 1 capsule(s) by mouth once a day in the morning Disp #30 Capsule Refills:0 4. Polyethylene Glycol 17 g PO Q6H:PRN Constipation - Third Line 5. Gabapentin 300 mg PO QHS RX gabapentin 300 mg 1 capsule(s) by mouth nightly Disp #30 Capsule Refills:*0 6. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain in rectum 7. NIFEdipine (bulk) 2 % rectal BID prn rectal pain 8. ValACYclovir 500 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Abdominal Pain Secondary Diagnoses: Reducible Hernia HSV suppression Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Dr. ___ was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You had pain in your abdomen. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had an x-ray which was not worrisome for obstruction - We monitored you for a few days. - We performed an ultrasound that showed a hernia. This hernia does not need urgent intervention but you should follow up with surgeons when you leave. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19832014-DS-7	19,832,014	22,531,080	DS	7	2188-06-01 00:00:00	2188-06-15 10:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Laparoscopic appendectomy History of Present Illness: ___ with no significant PMH/PSH who presents with 3 days of abdominal pain, initially associated with fevers/chills, and nausea. She reports being in her usual state of health when she noted an acute onset of malaise, associated with fevers/chills and initially vague mid-abdominal pain which then migrated to the RLQ and has intensified in the past day. The fevers/chills resolved 2 days prior without intervention, but the pain has persisted and worsened. She has also had associated nausea, but no vomiting, and has a had a decrease in appetite. No similar such episodes in the past, no sick contacts. She has been passing flatus and having normal BMs, most recently 2 days ago. No CP/SOB, no dysphagia, no BRBPR/melena. Past Medical History: Past Medical History: None Past Surgical History: ___ eye surgery Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: 97.6 66 ___ 99%RA GEN: A&O, NAD, interactive and cooperative HEENT: No scleral icterus CV: RRR PULM: Clear to auscultation b/l ABD: Soft, non-distended, tender to palpation in RLQ with no rebound/rigidity/guarding, no palpable masses Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: T: 98.2, BP: 115/67, HR: 90, RR: 18, O2: 93% RA GEN: A+Ox3, NAD CV: RRR, no m/r/g PULM: CTA b/l ABD: soft, mildly distended, mildly tender at incisions. Laparoscopic sites w/ steri-strips, gauze and tegaderm c/d/i EXT: warm, well-perfused, no edema b/l Pertinent Results: IMAGING: ___: US Appendix: 1. Small amount of complex pelvic free fluid with internal septations and echogenic material and without vascularity, centered in the right adnexa medial to the right ovary. This appearance is nonspecific, differential includes hemorrhagic fluid from recent ruptured cyst which is not currently seen, infection, and hydrosalpinx/salpingitis given linear nature of the collection. 2. Normal ovaries. 3. Appropriately positioned IUD. 4. Appendix not visualized. ___: Renal US: Unremarkable renal ultrasound. No evidence of renal calculi. ___: Transvaginal Pelvic US: 1. Small amount of complex pelvic free fluid with internal septations and echogenic material and without vascularity, centered in the right adnexa medial to the right ovary. This appearance is nonspecific, differential includes hemorrhagic fluid from recent ruptured cyst which is not currently seen, infection, and hydrosalpinx/salpingitis given linear nature of the collection. 2. Normal ovaries. 3. Appropriately positioned IUD. 4. Appendix not visualized. ___: CT Abdomen/Pelvis: Findings concerning for acute appendicitis. Note, due to the position of the cecum, the appendix extends posteriorly into the right hemipelvis. LABS: ___ 07:24PM ___ PTT-28.8 ___ ___ 01:48PM GLUCOSE-80 UREA N-18 CREAT-0.8 SODIUM-139 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18 ___ 01:48PM WBC-8.4 RBC-4.50 HGB-13.8 HCT-42.8 MCV-95 MCH-30.7 MCHC-32.2 RDW-11.9 RDWSD-41.6 ___ 01:48PM NEUTS-66.2 ___ MONOS-7.7 EOS-0.5* BASOS-0.2 IM ___ AbsNeut-5.53 AbsLymp-2.09 AbsMono-0.64 AbsEos-0.04 AbsBaso-0.02 ___ 01:48PM PLT COUNT-178 ___ 01:35PM URINE UCG-NEGATIVE ___ 01:35PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:35PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 ___ 01:35PM URINE MUCOUS-RARE Brief Hospital Course: Ms. ___ is a ___ y/o F with no pmh, who was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis. On HD1, the patient underwent laparoscopic appendectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor on IV fluids, and po oxycodone and acetaminophen for pain control. The patient was hemodynamically stable. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. On POD #1, the patient had a urine test positive for chalymadia trachomatis. The patient was informed of this finding and she was written for a one time dose of azithromycin 1gm and an educational packet was provided. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: ___ IUD Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID please hold for loose stool 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild please take with food 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate do NOT drink alcohol or drive while taking this medication RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. You were admitted to the hospital with acute appendicitis (inflammation of your appendix). You were taken to the operating room and had your appendix removed laparoscopically. This procedure went well, you are now tolerating a regular diet and your pain is better controlled. You are now ready to be discharged home to continue your recovery. Please follow the discharge instructions below to ensure a safe recovery while at home: Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
19832461-DS-14	19,832,461	25,403,408	DS	14	2164-12-29 00:00:00	2164-12-29 19:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nausea, abdominal discomfort, bloating Major Surgical or Invasive Procedure: paracentesis History of Present Illness: ___ G0 female with infertility undergoing IVF, s/p egg retrieval on ___, presents to ED with worsening abdominal distension, bloating, nausea and lightheadedness. Pt underwent first egg retrieval in ___ and had mild OHSS. Had poor response with low numbers of eggs retrieved. Never had nausea, but had worsening abdominal distension. Did not require paracentesis, ED visit or admission. Did end up having embryo transfer but did not conceive. This round, she underwent protocol with HCG trigger. Had lots of eggs retrieved. Reports no symptoms on POD#1 and 2 after retrieval, but started having sx three days ago that have been gradually worsening. Describes severe bloating and diffuse abdominal discomfort for past two days. c/o ongoing nausea, dry heaving, minimal emesis, poor appetite, PO tolerance. c/o swelling in stomach, back, rib cage. c/o inability to take full deep breaths. c/p difficulty ambulating, due to pain, lightheaded, dizziness. Has been home in bed for most of last two days, feels terrible sitting up. Took Zofran at home 3x in past 24 hours, with minimal relief. Also took Tylenol, ___ q6h, for past 2 days. No narcotics or anti-anxiety meds. In ED so far, has received liquid Zofran with minimal improvement. Is on ___ L of IVF. Endorses sweats and chills, after dry heaving. No fever. ROS negative for localized lower abdominal pain or focal tenderness. No vaginal bleeding. No chest pain, palpitations at rest. Got 8 days of cabergoline, today would be last day. If did not take home, 1 dose of 0.5 PO. Past Medical History: ObHx: -G0 GynHx: -Infertility, undergoing IVF, s/p ___ egg retrieval on ___ -Denies hx of ovarian cysts, fibroids -Remote hx of abnl paps, no surgeries -Has a stitch in her cervix, placed on day of retrieval PMH: -Denies PSH: -Tonsillectomy Social History: ___ Family History: non contributory Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, slightly distended, no rebound/guarding Ext: no TTP Pertinent Results: ___ 07:00AM BLOOD WBC-13.4* RBC-4.48 Hgb-13.8 Hct-40.8 MCV-91 MCH-30.8 MCHC-33.8 RDW-12.7 RDWSD-42.2 Plt ___ ___ 03:00PM BLOOD WBC-16.1* RBC-4.95 Hgb-15.5# Hct-45.0# MCV-91 MCH-31.3 MCHC-34.4 RDW-12.6 RDWSD-41.6 Plt ___ ___ 06:33AM BLOOD WBC-20.6* RBC-6.09* Hgb-19.1* Hct-55.2* MCV-91 MCH-31.4 MCHC-34.6 RDW-12.6 RDWSD-41.5 Plt ___ ___ 04:45PM BLOOD WBC-21.7* RBC-5.65* Hgb-17.5* Hct-50.7* MCV-90 MCH-31.0 MCHC-34.5 RDW-12.4 RDWSD-41.0 Plt ___ ___ 10:50AM BLOOD WBC-22.4* RBC-5.88* Hgb-18.5* Hct-53.6* MCV-91 MCH-31.5 MCHC-34.5 RDW-12.7 RDWSD-41.1 Plt ___ ___ 06:49AM BLOOD WBC-25.3* RBC-6.13* Hgb-19.6* Hct-55.3* MCV-90 MCH-32.0 MCHC-35.4 RDW-13.0 RDWSD-41.7 Plt ___ ___ 06:33AM BLOOD Neuts-76.3* Lymphs-16.0* Monos-6.2 Eos-0.3* Baso-0.3 Im ___ AbsNeut-15.74* AbsLymp-3.30 AbsMono-1.27* AbsEos-0.07 AbsBaso-0.06 ___ 06:49AM BLOOD Neuts-86.8* Lymphs-8.8* Monos-3.1* Eos-0.0* Baso-0.4 Im ___ AbsNeut-21.92* AbsLymp-2.22 AbsMono-0.78 AbsEos-0.01* AbsBaso-0.09* ___ 07:00AM BLOOD Plt ___ ___ 03:00PM BLOOD Plt ___ ___ 06:33AM BLOOD Plt ___ ___ 04:45PM BLOOD Plt ___ ___ 10:50AM BLOOD Plt ___ ___ 10:50AM BLOOD ___ PTT-26.7 ___ ___ 06:49AM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-71 UreaN-18 Creat-1.0 Na-135 K-4.5 Cl-104 HCO3-23 AnGap-13 ___ 03:00PM BLOOD Glucose-79 UreaN-18 Creat-1.1 Na-131* K-5.3* Cl-99 HCO3-25 AnGap-12 ___ 06:33AM BLOOD Glucose-126* UreaN-19 Creat-1.2* Na-130* K-5.3* Cl-98 HCO3-23 AnGap-14 ___ 04:45PM BLOOD Glucose-107* UreaN-21* Creat-1.1 Na-132* K-5.2* Cl-98 HCO3-20* AnGap-19 ___ 10:50AM BLOOD Glucose-116* UreaN-23* Creat-1.2* Na-126* K-5.3* Cl-94* HCO3-20* AnGap-17 ___ 06:49AM BLOOD Glucose-115* UreaN-25* Creat-1.2* Na-126* K-5.3* Cl-93* HCO3-20* AnGap-18 ___ 06:33AM BLOOD ALT-12 AST-22 ___ 04:45PM BLOOD ALT-9 AST-18 ___ 06:49AM BLOOD ALT-12 AST-21 AlkPhos-55 TotBili-0.3 ___ 07:00AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.0 ___ 03:00PM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0 ___ 06:33AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0 ___ 04:45PM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8 ___ 10:50AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.7 ___ 06:49AM BLOOD Albumin-3.4* Calcium-9.0 Phos-4.9* Mg-1.8 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service with bloating, abdominal discomfort, and nausea, found to have lab abnormalities including hemoconcentration, hyponatremia, and ___, concerning for severe ovarian hyperstimulation syndrome. Ultrasound in the emergency department had showed severe ascites, 12 cm ovaries, with normal ovarian flow. Chest XR showed no pulmonary edema. She received 2L normal saline bolus and 50 mg albumin in the emergency department. She underwent therapeutic paracentesis on ___, during which 3.3L serosanguinous fluid was drained. Her electrolytes and blood counts were trended Q6 hours initially, then were spaced to daily throughout the course of her stay. She received IV fluids as needed for hemoconcentration (3L on ___, 2L on ___, with one dose of albumin daily). She finished her 8 day course of cabergoline on ___. Her diet was advanced, which she tolerated well without nausea or vomiting. Her electrolytes and creatinine improved significantly throughout the course of her stay (see "labs" section). By ___, she was tolerating a regular diet with reassuring and improved labs and was symptomatically improved. She was discharged home with instructions for close follow up. Medications on Admission: -Tylenol prn -Zofran prn -completing course of cabergoline Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild RX acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #20 Tablet Refills:1 Discharge Disposition: Home Discharge Diagnosis: ovarian hyperstimulation syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service with "ovarian hyperstimulation syndrome," which is a complication from your infertility treatment. We drained some fluid from your abdomen, monitored your electrolytes and blood counts, which improved, and you recovered well. The team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. Call your doctor for: fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
19832679-DS-15	19,832,679	22,464,275	DS	15	2133-03-30 00:00:00	2133-03-30 13:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: transient right lower extremity weakness/numbness Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Mr. ___ is a ___ year old right handed male with history of atrial fibrillation on Eliquis, prior R retinal artery occlusion in ___ with central right visual loss, AVR repair in ___ who presents with transient episode right leg weakness then transient episode left arm weakness. This morning at 0800 he was walking and suddenly felt like his right leg was weak and numb. He did not fall and continued walking. This subsided in about 5 minutes. Then shortly after this he developed left upper extremity weakness. This was subtle and resolved in minutes. He was able to go about performing all his usual tasks. Then after lunch, he had another several minute episode or right lower extremity weakness and numbness. Again, he was able to walk and carry out usual function. He denies other symptoms such as dysarthria, speech difficulty or changes in his vision. Due to these symptoms, he decided to come to the hospital. He admits to missing doses of Eliquis recently. He does note that he feels like he has been in atrial fibrillation for the past month. He does note that about 2 weeks ago he had an episode of left sided chest pressure without radiation. This was not exertional. Since this time, he does note feeling more fatigued and perhaps more dyspnea on exertion. Of note, no recent illness, no abdominal pain, no diarrhea, no vomiting, no fevers, no chills, no weight loss. ROS: positive as above, 10 pnt ROS otherwise negative Past Medical History: Dyslipidemia Aortic Stenosis Atrial Fibrillation s/p DCCV Partial retinal occlusion Pneumonia Social History: ___ Family History: Mother with ___ and aortic valve disease Physical Exam: PHYSICAL EXAMINATION: Vitals: reviewed General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Slightly smaller right palpebral fissure. VFF to confrontation, does have central vision loss on right. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. ___ absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. Slight dysmetria on FNF and mirroring on the left. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. ++++++++++++++++++++++++++ DISCHARGE Physical Exam: 24 HR Data (last updated ___ @ 805) Temp: 97.8 (Tm 98.3), BP: 123/86 (121-150/85-108), HR: 72 (70-75), RR: 18, O2 sat: 96% (94-96), O2 delivery: Ra General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: skin warm, well-perfused. Abdomen: soft, ND Extremities: Symmetric, no edema. -Mental Status: Alert, oriented x 3. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Naming intact to high and low frequency objects. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL . VFF to confrontation. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric at rest and with activation. Hearing intact to conversation. Palate elevates symmetrically. ___ strength in trapezii bilaterally. Tongue protrudes in midline and moves briskly to each side. No dysarthria. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: Proprioception intact BUE. Intact to LT throughout. No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach Pec jerk Crossed Adductors L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. Pertinent Results: ___ 08:09AM BLOOD WBC-5.7 RBC-5.03 Hgb-14.3 Hct-43.0 MCV-86 MCH-28.4 MCHC-33.3 RDW-13.3 RDWSD-41.3 Plt ___ ___ 06:25PM BLOOD WBC-6.1 RBC-4.67 Hgb-13.9 Hct-40.1 MCV-86 MCH-29.8 MCHC-34.7 RDW-13.4 RDWSD-41.8 Plt ___ ___ 06:25PM BLOOD Neuts-59.3 ___ Monos-9.6 Eos-2.1 Baso-1.0 Im ___ AbsNeut-3.64 AbsLymp-1.69 AbsMono-0.59 AbsEos-0.13 AbsBaso-0.06 ___ 08:09AM BLOOD Plt ___ ___ 06:25PM BLOOD ___ PTT-33.1 ___ ___ 08:09AM BLOOD Glucose-99 UreaN-11 Creat-0.9 Na-140 K-4.2 Cl-103 HCO3-27 AnGap-10 ___ 06:25PM BLOOD Glucose-93 UreaN-12 Creat-1.0 Na-138 K-5.9* Cl-103 HCO3-23 AnGap-12 ___ 08:09AM BLOOD ALT-14 AST-17 AlkPhos-44 TotBili-0.7 ___ 06:25PM BLOOD ALT-17 AST-55* AlkPhos-31* TotBili-0.5 ___ 08:09AM BLOOD Lipase-485* ___ 06:25PM BLOOD Lipase-839* ___ 06:25PM BLOOD cTropnT-<0.01 ___ 06:25PM BLOOD CK-MB-3 ___ 08:09AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1 ___ 06:25PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.5 Mg-2.1 Cholest-208* ___ 06:25PM BLOOD %HbA1c-5.3 eAG-105 ___ 06:25PM BLOOD Triglyc-144 HDL-53 CHOL/HD-3.9 LDLcalc-126 ___ 06:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 06:25PM BLOOD GreenHd-HOLD CXR IMPRESSION: No acute cardiopulmonary process. TTE CONCLUSION: The left atrial volume index is mildly increased. The right atrium is moderately enlarged. There is no evidence of an atrial septal defect or patent foramen ovale by 2D/color Doppler or agitated saline at rest and with maneuvers. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 60 %. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated. An aortic valve bioprosthesis is present. The prosthesis is well seated with normal gradient. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. CTA HEAD AND NECK IMPRESSION: 1. Focal left V4 segment atherosclerotic plaque without significant narrowing. No evidence of high-grade stenosis, occlusion, or aneurysm of the carotid or vertebral arteries. 2. Aneurysmally dilated ascending aorta measuring 4.7 cm. Further evaluation with dedicated CTA of the chest is recommended if not previously worked up. 3. Enlarged main pulmonary artery measuring 3.6 cm. Findings may be secondary to pulmonary arterial hypertension. RECOMMENDATION(S): Aneurysmally dilated ascending aorta measuring 4.7 cm. Further evaluation with dedicated CTA of the chest is recommended if not previously worked up. ABDOMINAL US IMPRESSION: 1. Cholelithiasis, without additional evidence of acute cholecystitis. Specifically, a stone is noted in the gallbladder neck. 2. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. Brief Hospital Course: In brief, Mr. ___ is a ___ year old right handed male with history of atrial fibrillation on apixaban, prior R retinal artery occlusion in ___ with central right visual loss, AVR repair in ___ who presented with transient episode right leg weakness then transient episode left arm weakness in the setting of recent non-compliance with taking apixaban. On arrival he was asymptomatic. His exam was only notable for chronic right central vision loss as well as mild left dysmetria on finger nose finger. ___ showed no acute ischemia or hemorrhage, CTA head and neck showed no large vessel occlusion. We think his presentation is most concerning for transient ischemic attack most likely from a cardioembolic source given his known history of atrial fibrillation and several missed doses of apixaban. A trans-thoracic echo showed no cardiacembolic source. Atorvastatin was started for an LDL level of 126. Incidentally we noted an elevated lipase of 800 on admission. There were no abdominal symptoms. An abdominal ultrasound was negative for cholecystitis or pancreatitis. Gallstones were noted. His lipase improved to 52 (normal) prior to discharge. Also incidentally noted on his CTA was an aneurysmal ascending aorta measuring up to 4.7 cm. Evaluation by vascular surgery as an outpatient is recommended. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Transitional issues: -Optimization of stroke risk factors [atrial fibrillation, hypercholesterolemia] -Continue apixaban at 5 mg twice daily -Follow-up in stroke clinic -Follow-up with vascular surgery regarding the incidentally found aortic aneurysm +++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Transitional issues: -Optimization of stroke risk factors [atrial fibrillation, hypercholesterolemia] -Continue apixaban at 5 mg twice daily -Follow-up in stroke clinic -Follow-up with vascular surgery regarding the incidentally found aortic aneurysm ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 126 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - If no, why not (I.e. bleeding risk, etc.) () N/A Medications on Admission: Eliquis 5 mg BID Discharge Medications: 1. Apixaban 5 mg PO BID RX apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:3 2. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:3 Discharge Disposition: Home Discharge Diagnosis: Transient ischemic attack Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were hospitalized due to symptoms of transient right leg weakness and numbness and transient left arm weakness likely resulting from a TRANSIENT ISCHEMIC ATTACK, a condition where a blood vessel providing oxygen and nutrients to the brain is temporarily blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. TRANSIENT ISCHEMIC ATTACKS (TIAs) can have many different causes, so we assessed you for medical conditions that might raise your risk of having TIAs. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - Atrial fibrillation - High cholesterol - Missing doses of your apixaban(blood thinner) We are changing your medications as follows: -Please continue taking apixaban 5 mg twice daily, it is really important that you do not miss any doses -Please start atorvastatin at 40 mg nightly Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
19833444-DS-7	19,833,444	26,200,197	DS	7	2176-01-08 00:00:00	2176-01-09 07:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: bacitracin / Keflex / nickel Attending: ___. Chief Complaint: dysarthria Major Surgical or Invasive Procedure: None History of Present Illness: This is an ___ year old woman with afib on eliquis, CAD, CHFpEF, HTN, HLD, hypothyroidism who presents to ___ ED from ___ for evaluation of cerebellar hemorrhage found on outpatient MRI for workup of dysarthria. History obtained by patient and per chart review. Mrs. ___ reports that the was feeling well up until ___ when she received a shingles shot. After receiving the shingles shot, she has noticed that her speech became slurred. She associates this with a shingles shot that she received because that is one of the adverse effects that she read as part of the shot information page and so she didn't think much of it. For the next ___ days she felt very unwell, with general malaise but no nausea or vomiting. She thought maybe she was having a mild cold-like reaction to the shot. Yesterday, she saw her therapist who became concerned. Her nephew also became concerned, noting that she persistently sounds as if she has a swollen tongue. She thus presented to outpatient for further evaluation who ordered an MRI which demonstrated cerebellar hemorrhage. She was thus transferred to ___ for further workup. She notes she has been adherent with her eliquis and took it this morning. She gets high blood pressure mostly in hospitals or doctor offices but otherwise thinks her pressure has been running well. Prior to ___, she has not noticed any worsening gait instability, slurred speech, veering to one side, difficulty swallowing, double vision, sensory changes. No fever, chills. She does note that she has a history of headaches for which she takes fioricet. She got a "terrible" headache two days ago but this was consistent with her typical headaches and resovled with 1xtablet fioricet. Regarding cancer screening, she notes that she has had two skin lesions that have recently been removed that she thought were cancerous but she does not recall the details. She has had a hysterectomy for fibroids but no malignancy. She is up to date on her colonoscopy (last one ___ years ago). She has not smoked for decades. ROS: === Notable for above findings, otherwise noncontributory. Past Medical History: afib CHFpEF HTN hyperlipidemia miraines CAD s/p 3x spine laminectomes (___, ___, ___ s/p surgical repair of chest wall when she was a child s/p detached retina in ___ with buckle placement s/p afib ablation w persistent afib Social History: ___ Family History: breast cancer in maternal grandmother hearing loss in mother, heart disease in brother and father ovarian cancer in maternal grandfather uterine cancer in hre mother Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: afebrile, HR70s, BP174/93, RR14, 98RA General: Appears much younger than stated age HEENT: She has a split uvula, otherwise normal. Neck: Supple Pulmonary: Normal work of breathing. Cardiac: irregular, normal rate Abdomen: Soft, Extremities: trace pedal edema MsK: right foot is in brace for foot drop, right arm in brace for carpal tunnel, trigger finger on left index finger Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: Pupils post-surgical. 3>2 bilateral. EOMI. ___ beats direction changing nystagmus. No vertical nystagmus. Endorses slight blurry vision on right lateral gaze but no diplopia. Slight right NLFF with symmetric activation. Uvula deviates to the right although difficult to assess as it is sokit. Strong cough. No gag. Dysarthric with pronounciation of gutteral sounds. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. Bilateral rotator cuff injuries restrict range of motion at delt. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA L * 5 5 5 5 5 4 4 4 * R * 5 5 5 5 5 4 4 4 4 cannot fully assess secondary to pain from rotator cuff injuries/frozen shoulders (at baseline per patient) *Brace on left foot for foot drop (at baseline) Lower extremity confrontational strength testing is limited by effort and knee/hip pain at baseline -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 0 0 R 2 2 2 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No obvious deficit with finger tapping. FNF intact without dysmetria. DISCHARGE PHYSICAL EXAM ======================== General: elderly woman, NAD HEENT: ATNC Neck: Supple Pulmonary: Normal work of breathing. Cardiac: irregular, normal rate Abdomen: Soft, Extremities: trace pedal edema MsK: right arm in brace for carpal tunnel Neurologic: -Mental Status: Alert, conversant, speaking in full sentences -Cranial Nerves: Pupils post-surgical. 3>2 bilateral. end gaze nystagmus bilateral horizontal gaze. -Motor: Able to lift all limbs antigravity on command, although has chronic R foot drop. R arm somewhat limited due to rotator cuff injury -Sensory: deferred -Coordination: FNF intact without dysmetria. Pertinent Results: ADMISSION LABS ============== ___ 08:40PM BLOOD WBC-6.6 RBC-3.88* Hgb-11.5 Hct-36.2 MCV-93 MCH-29.6 MCHC-31.8* RDW-13.5 RDWSD-45.8 Plt ___ ___ 08:40PM BLOOD Neuts-44.5 ___ Monos-11.3 Eos-2.6 Baso-0.3 Im ___ AbsNeut-2.94 AbsLymp-2.72 AbsMono-0.75 AbsEos-0.17 AbsBaso-0.02 ___ 08:40PM BLOOD ___ PTT-34.1 ___ ___ 08:40PM BLOOD Plt ___ ___ 08:40PM BLOOD Glucose-95 UreaN-17 Creat-0.6 Na-140 K-4.7 Cl-98 HCO3-29 AnGap-13 DISCHARGE LABS ============== ___ 06:55AM BLOOD WBC-6.3 RBC-3.95 Hgb-11.7 Hct-36.9 MCV-93 MCH-29.6 MCHC-31.7* RDW-13.5 RDWSD-46.7* Plt ___ ___ 06:55AM BLOOD Plt ___ ___ 06:55AM BLOOD ___ PTT-31.6 ___ ___ 06:55AM BLOOD Glucose-91 UreaN-18 Creat-0.6 Na-142 K-3.7 Cl-101 HCO3-28 AnGap-13 IMAGING ======= MR HEAD W/O CONTRAST Study Date of ___ FINDINGS: 1.6 cm x 1.2 cm subacute hematoma medial right cerebellum centered at dentate nucleus, mild surrounding edema. Linear peripheral enhancement, typical of subacute hematoma. Other punctate foci of susceptibility are seen in the left thalamus, left frontal lobe. No abnormal leptomeningeal enhancement. Mild opacification left mastoids. Preserved vascular flow voids. There is no evidence of midline shift. Brain parenchymal atrophy. Findings consistent with moderate chronic small vessel ischemic changes. There is no abnormal enhancement after contrast administration. IMPRESSION: 1. Subacute hematoma right cerebellum. MR HEAD W & W/O CONTRAST Study Date of ___ IMPRESSION: 1. Subacute hematoma right medial cerebellum. Follow-up to resolution recommended. 2. Subtle leptomeningeal enhancement left vertex, may be normal vessel, consider inflammatory, infectious or neoplastic etiology, follow-up recommended. TTE ___ IMPRESSION: Moderate pulmonary artery systolic hypertension. Mildly dilated thoracic aorta. Mild aortic regurgitation with mildly thickened leaflets. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Mild mitral regurgitation. No definite structural cardiac source of embolism identified. Brief Hospital Course: Ms. ___ is an ___ woman with a past medical history of atrial fibrillation on eliquis, CAD, CHFpEF, HTN, HLD, and hypothyroidism who presented from ___ for evaluation of cerebellar hemorrhage found on outpatient MRI for workup of dysarthria. #Subacute right cerebellar hemorrhage: Initial NIHSS 2 (facial palsy, dysarthria). MRI brain with chronic microbleed in the left frontal and left thalamic areas as well as small area of leptomeningeal enhancement at the left vertex for which the differential is broad, no signs of infectious or inflammatory process. Etiology of bleed most likely hypertensive in setting of anticoagulation. Another possibility is that she has cerebral amyloid angiopathy that contributed to this bleed. A neoplastic process with hemorrhagic conversion is less likely. SBP on presentation 170s. Continued home amlodipine, furosemide, metoprolol succinate, and atorvastatin. Held anticoagulation. Risk factors notable for A1C 5.5, LDL 57. Discharged with home ___ and speech services. At time of discharge, exam notable for bilateral end gaze nystagmus. TRANSITIONAL ISSUES: ==================== [] f/u repeat CT head to be performed 2 weeks after discharge, ordered prior to discharge [] f/u repeat MRI brain with and w/o contrast to be performed 2 months after discharge, ordered prior to discharge [] held anticoagulation following cerebral hemorrhage, consider restarting after interval imaging complete AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (bleeding risk, hemorrhage, etc.) 3. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Levothyroxine Sodium 112 mcg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Lubiprostone 24 mcg PO BID 5. TraMADol 50 mg PO BID 6. Gabapentin 1200 mg PO BID 7. DULoxetine 20 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 9. DICYCLOMine 10 mg PO TID 10. Atorvastatin 80 mg PO QPM 11. amLODIPine 10 mg PO DAILY 12. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. DULoxetine 40 mg PO 4X/WEEK (___) 3. DULoxetine 20 mg PO 3X/WEEK (___) RX duloxetine 20 mg 1 capsule(s) by mouth Daily Disp #60 Capsule Refills:0 4. Atorvastatin 80 mg PO QPM 5. DICYCLOMine 10 mg PO TID 6. Furosemide 40 mg PO DAILY 7. Gabapentin 1200 mg PO BID 8. Levothyroxine Sodium 112 mcg PO DAILY 9. Lubiprostone 24 mcg PO BID 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 12. TraMADol 50 mg PO BID 13. HELD- Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until instructed by your doctor 14.Outpatient Physical Therapy Home physical therapy ICD10: I61.9 15.Outpatient Speech/Swallowing Therapy Outpatient, home speech therapy ICD10: I___.9 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: #Subacute right cerebellar hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of difficulty with speech resulting from an ACUTE STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain leaks blood. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: 1) atrial fibrillation on anticoagulation 2) high blood pressure We are changing your medications as follows: 1) holding your anticoagulation ("eliquis") Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
19833452-DS-10	19,833,452	21,712,950	DS	10	2142-04-04 00:00:00	2142-04-04 17:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Evista / ketoprofen / omeprazole / Penicillins / simvastatin / tizanidine / Zometa Attending: ___. Chief Complaint: dyspnea, acute on chronic hypercapnic respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with PMHx of HFpEF (TTE ___ EF 65%), A. fib on apixiban, CKD Stage III, DM, who initially presented to ___ for lethargy and SOB, and now subsequently transferred to ___ for ICU bed in setting of hypercapnic respiratory failure requiring BiPAP. Patient initially presented from ___ (___ at ___ to ___ with 1 day of dyspnea and lethargy. On arrival to ___, she was tachypneic to the ___ and unable to complete full sentences. History was limited as patient had altered mental status and was not fully able to participate in interview. She had chest x-ray which showed volume overload as well as opacity concerning for pneumonia. She was noted to be febrile to 100.4. Labs at ___ were notable for BNP of 20,000 and white count of 12. UA was negative. She had an ABG with 7.32/100/74. She received cefepime and 40 mg furosemide IV and was started on BiPAP. Transfer to ___ was initiated given lack of ICU beds at ___. On arrival to ___ ED, she was tachypneic to ___ and agitated on the BiPAP mask. Foley was noted to have 600cc urine. She was trialed off BiPAP; VBG off BiPAP was obtained which resulted 7.28/80. Given agitation with BiPAP she was transitioned to ___ prior to transfer to ___. In the ED, - Initial Vitals: HR 83 BP 134/69 RR18 O2-99 RA - Exam: GENERAL: Agitated, combative, and soft restraints HEENT: NCAT, moist mucous membranes CV: RRR, s1/s2, no s3/s4, no m/r/g, radial pulses equal bilaterally, skin warm and well perfused PULM: Lung exam limited by agitated status, no frank rales, no accessory mm. use ABDOMINAL: NTND, no rebound/guarding, no peritonitic signs GU: no CVAT MSK: Full ROM, no joint swelling, no erythema EXTREMITIES: 1+ pitting edema bilateral lower extremity NEURO: freely moving all extremities - Labs: BNP 24864 Trop 0.04 CKMB 2 VBG off BiPAP ___ - Imaging: CXR - Potential left basilar patchy opacity, which may reflect atelectasis with infection not excluded, though assessment is limited without a lateral view. - Interventions: none Upon arrival to the FICU, she is intermittently alert and oriented. She states that she is in the hospital due to having too much fluid. She endorses SOB and cough. Denies any sputum production. She denies chest pain, abdominal pain, constipation, diarrhea, or dysuria, no bleeding. Past Medical History: CHF Afib (on apixiban) CKD Stage 3 HTN T2DM Hypothyroidism GERD Bilateral hip replacement Remote left breast cancer Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: T 98.2 HR81 BP106/37 RR26 O2:100 GEN: sleepy, tachypneic, in NAD HENNT: PEERL, EOMI, no icterus, MMM CV: irregular rate and rhythm, no M/R/G, JVD elevated RESP: bibasilar crackles + rhonchi GI: soft, non-tender, non-distended, no rebound/guarding EXT: 2+ bilateral pitting ___ NEURO: oriented to place, month and year; face symmetric, moving all extremities DISCHARGE PHYSICAL EXAM ======================== 97.4 BP:119/61 HR:68 R:20 o2:93% RA GENERAL: Alert and in no apparent distress, speaking in full sentences EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Hard of hearing CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Clear on anterior auscultation GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes noted NEURO: Alert, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. AAO X 3. Knows day of week and able to ___ backwards. PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS ============== ___ 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 10:27PM ___ PO2-27* PCO2-80* PH-7.28* TOTAL CO2-39* BASE XS-5 ___ 10:27PM LACTATE-1.3 ___ 10:20PM GLUCOSE-100 UREA N-29* CREAT-1.1 SODIUM-145 POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-36* ANION GAP-12 ___ 10:20PM cTropnT-0.04* ___ 10:20PM CK-MB-2 ___ ___ 10:20PM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-1.5* ___ 10:20PM WBC-13.0* RBC-3.43* HGB-8.5* HCT-30.2* MCV-88 MCH-24.8* MCHC-28.1* RDW-19.3* RDWSD-62.4* ___ 10:20PM NEUTS-78.9* LYMPHS-8.7* MONOS-10.1 EOS-1.0 BASOS-0.3 IM ___ AbsNeut-10.28* AbsLymp-1.13* AbsMono-1.32* AbsEos-0.13 AbsBaso-0.04 MICRO/OTHER PERTINENT LABS ========================== ___ 02:34AM BLOOD Ret Aut-2.4* Abs Ret-0.08 ___ 10:20PM BLOOD CK-MB-2 ___ ___ 10:20PM BLOOD cTropnT-0.04* ___ 02:34AM BLOOD Iron-11* ___ 02:34AM BLOOD calTIBC-228* VitB12-777 Ferritn-257* TRF-175* ___ 10:00PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG IMAGING ======== CXR ___ Potential left basilar patchy opacity, which may reflect atelectasis with infection not excluded, though assessment is limited without a lateral view. CXR ___: In comparison with the study of ___, the there again is substantial enlargement of the cardiac silhouette with some improvement in the degree of pulmonary edema. The right hemidiaphragmatic contour is more sharply seen, consistent with improving pleural effusion. Retrocardiac opacification again is consistent with volume loss in the left lower lobe and pleural fluid. Round opacification in the left humeral head most likely represents a benign bone island. If the patient has a condition associated with sclerotic metastases, further imaging could be obtained if clinically warranted. CXR: ___ IMPRESSION: Interval improvement in the degree of pulmonary vascular congestion. Stable bilateral pleural effusions. ECG: ___ Typical atrial flutter with variable conduction and isolated premature ventricular contractions versus aberrantly conducted ventricular complexes. Underlying right bundle-branch block. Compared to the previous tracing of ___ the rhythm is more organized and consistent with atrial flutter. The ventricular response is controlled. DISCHARGE LABS =============== ___ 07:50AM BLOOD WBC-8.2 RBC-3.66* Hgb-8.8* Hct-31.1* MCV-85 MCH-24.0* MCHC-28.3* RDW-18.2* RDWSD-56.9* Plt ___ ___ 06:12AM BLOOD ___ PTT-31.3 ___ ___ 08:00AM BLOOD Glucose-102* UreaN-28* Creat-1.3* Na-141 K-4.8 Cl-95* HCO3-37* AnGap-9* ___ 10:20PM BLOOD CK-MB-2 ___ ___ 10:20PM BLOOD cTropnT-0.04* ___ 08:00AM BLOOD proBNP-3821* ___ 02:34AM BLOOD calTIBC-228* VitB12-777 Ferritn-257* TRF-175* Brief Hospital Course: PA andMs. ___ is a ___ woman with PMHx of HFpEF (TTE ___ EF 65%), afib on apixiban, CKD Stage III, DM, who initially presented to ___ for lethargy and SOB, and was subsequently transferred to ___ ICU due to hypercapnic respiratory failure requiring BiPAP. # Acute on likely chronic hypercapnic respiratory failure # Acute HFpEF exacerbation # Fever, leukocytosis. Severe sepsis with ___ Presented with hypoxia as well as acute on chronic hypercapnia (pCO2 ___ with pH 7.27-7.28). She has history of elevated HCO3 in outpatient labs suggestive of chronic compensation for respiratory acidosis. She was trialed on BIPAP in the ICU with no significant improvement in CO2 retention. There was no clear cause of chronic respiratory acidosis and she has no known COPD. She was found to be volume overloaded with likely pneumonia resulting in hypoxia at time of presentation. As mental status improved (see below) her VBG improved to a pH 7.37 with pCO2 65, likely baseline. Some degree of acute respiratory acidosis may have been related to lethargy/somnolence. TTE was obtained and was suggestive of right sided heart failure and severe pulmonary hypertension. This appears new compared to prior TTE from ___ in ___ system. V/Q scan was obtained to evaluate for PE given new right heart failure but was non-diagnostic (ventilation images unable to be obtained). Overall PE was felt to be unlikely given that she is chronically on apixaban and the elevated pulmonary pressures were likely due at least in part to volume overload. CXR was unable to rule out pneumonia and she was febrile at time of admission though this may have been due to aspiration. She was initially treated with vanc/cefepime/azithromycin which was narrowed to ceftriaxone/azithromycin to complete a 5 day course. She was diuresed with IV lasix boluses. And subsequently transitioned to oral torsemide. Her volume status was difficult to obtain as the patient cannot stand for weights. And is incontinent therefore ins and outs were not well documented. Chest x-rays and BNP's were followed. Chest x-ray improved and BNP trended down from ___ on admission to 3821 on the day of discharge. The patient's creatinine was slightly elevated on discharge indicating she is likely hypovolemic. With therefore recommending holding torsemide and repeating chemistry on ___ if creatinine is less than 1 would resume torsemide 20 mg p.o. daily. #Encephalopathy/Delirium Presented with lethargy. Likely toxic metabolic in the setting of respiratory failure and pneumonia. Improved with treatment of respiratory failure and possible pneumonia as above. The patient improved and was awake alert and oriented x3 on discharge she knew the day of the week and was able to do the months of the year backwards fluently. # ___ on CKD Cr 0.8 on last admission to ___ and elevated to 1.3 here. Likely pre-renal in setting of acute CHF exacerbation. Improved to baseline with diuresis and then began to rise again indicating the patient was likely hypovolemic/over diuresed. On discharge would hold the patient's diuretics repeat creatinine on ___ and if creatinine is less than 1.1 at that time start torsemide 20 mg p.o. daily. # Atrial flutter: The patient's dose of metoprolol was decreased on admission her she then developed rapid atrial flutter and her dose of metoprolol was increased with improved control. Apixiban was continued for anticoagulation. If the patient has ongoing rapid rates can consider addition of digoxin versus cardioversion. The patient has cardiology follow-up arranged on discharge. # Anemia Hg at baseline. Low iron saturation suggestive of iron deficiency Can consider IV iron prior to discharge. # Elevated INR: INR 3.1 on admission, improved to 2.7 with IV vitamin K. Does take apixaban. She was started on a PO vitamin K challenge with 5mg PO X 3 days with decrease in INR to 2.4. # GOC: Reviewed with the patient and her nephew. The patient is DNR/DNI. The patient had been seen by speech-language pathology during her hospitalization who recommended a modified diet. The patient and her nephew preferred to allow the patient to eat for comfort the patient should be on thin liquids with a soft solid diet # GERD: continued home omeprazole # DM Not on home insulin. Monitored TRANSITIONAL ISSUES ==================== - Please check Chem 7 on ___. If Creatinine is less than 1.1 start Torsemide 20mg daily - Patient should follow up with cardiology- to be contacted with appointment # Code Status: DNR/DNI, ok for NIV # Emergency Contact: ___, nephew, ___, HCP >30 minutes on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO QHS 2. Cetirizine 10 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 5. Multivitamins 1 TAB PO DAILY 6. Pyridoxine 50 mg PO DAILY 7. Cyanocobalamin 250 mcg PO DAILY 8. Docusate Sodium 100 mg PO DAILY 9. Mirtazapine 15 mg PO QHS 10. Apixaban 5 mg PO BID 11. Gabapentin 100 mg PO BID 12. Furosemide 40 mg PO DAILY 13. Metoprolol Tartrate 100 mg PO TID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pneumonia Acute on chronic diastolic CHF exacerbation Atrial flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, You were sent to the hospital because you were having difficulty breathing. You had Xrays of your chest which showed extra fluid in the lungs and also possibly a pneumonia. You were treated with antibiotics and medication to remove the extra fluid from the lungs. Your breathing improved and it is now safe for you to leave the hospital. It was a pleasure taking care of you. We wish you the best, Your ___ Care team Followup Instructions: ___
19833978-DS-17	19,833,978	22,368,455	DS	17	2125-05-17 00:00:00	2125-05-18 18:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: ETOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with a past medical history of alcohol abuse (drinking since age ___, recently in IOP program at ___), alcoholic hepatitis with 3 prior hospitalizations (no seizures), gastritis, and a right eye prosthesis, who presents for alcohol detox with labs concerning for alcoholic hepatitis. The patient was last admitted ~1 month ago with a similar presentation and his withdrawal was complicated by alcoholic hepatitis, blood-streaked emesis, confusion and hallucinations. Steroids were not given due to ___ score of 2.7. He was managed with diazepam and maalox for gastritis. Social work saw him and gave him resources to connect with IOP at ___ following discharge, which he did. His preference now is to go to an ___ facility but he was told his insurance didn't cover it. He recently presented to his PCP, ___, for addiction psychiatry referral, stating that he has been having ___ drinks a day and wanted referral to a psychiatrist. He claims that when he tries to stop drinking he feels high levels of anxiety but expressed a desire to quit drinking nonetheless. At the appointment, he was referred to Dr. ___ addiction psychiatrist at ___, and referred nonurgently to the ___. Today he presents for detox because he was told by his primary care doctor that his "liver is damaged." He says he drinks alcohol every day but does not drink a lot - he had stopped in ___ when he went to detox and rehab and had not had a drink in 3 weeks until yesterday. Endorses drinking 5 nips yesterday and 2 today after having a disagreement with his ex-wife. Also endorses marijuana use yesterday but denies other illicits. On review of systems, he reports diffuse abdominal pain that is constant and chronic in nature, worse with eating, and gnawing in nature. Past Medical History: - Depression with anxiety - Alcohol use disorder - Alcohol withdrawal syndrome without seizure - Chronic alcoholic gastritis without hemorrhage - Thrombocytopenia - Essential hypertension - Hyperlipidemia - History of acute pancreatitis (per patient) - Vitamin D deficiency - Chronic bilateral low back pain without sciatica - Prosthetic eye globe post traumatic injury Social History: ___ Family History: - Cancer - Other in his paternal uncle; - Depression in his sister; - Diabetes in his paternal uncle; - Heart Disease (age of onset: ___) in his paternal uncle; - Heart Disease (age of onset: ___) in his paternal grandmother; - Lipids in his father and mother. Physical Exam: GENERAL: Alert and interactive. In no acute distress. HEENT: Old scar on head, oral mucosa moist CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowel sounds, non distended. No tenderness. Soft. No LLQ pain, guarding, or rebound tenderness. EXTREMITIES: No cyanosis or edema. Pulses Radial 2+ bilaterally. SKIN: Warm and dry NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. Finger-to-nose intact, but mild intention tremor is apparent. Pertinent Results: ___ 11:30AM BLOOD WBC-2.7* RBC-3.88* Hgb-13.0* Hct-37.7* MCV-97 MCH-33.5* MCHC-34.5 RDW-13.7 RDWSD-49.1* Plt ___ ___ 06:55AM BLOOD WBC-4.0 RBC-3.45* Hgb-11.7* Hct-35.3* MCV-102* MCH-33.9* MCHC-33.1 RDW-13.7 RDWSD-51.9* Plt ___ ___ 07:10AM BLOOD ___ ___ 11:30AM BLOOD Glucose-102* UreaN-22* Creat-1.4* Na-137 K-4.1 Cl-97 HCO3-19* AnGap-21* ___ 06:20AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-141 K-5.0 Cl-100 HCO3-28 AnGap-13 ___ 11:30AM BLOOD ALT-322* AST-896* LD(LDH)-440* AlkPhos-760* TotBili-4.2* DirBili-3.0* IndBili-1.2 ___ 08:00AM BLOOD ALT-328* AST-964* LD(LDH)-383* CK(CPK)-98 AlkPhos-825* TotBili-7.0* ___ 10:25AM BLOOD ALT-256* AST-553* AlkPhos-754* TotBili-5.6* ___ 06:55AM BLOOD ALT-234* AST-373* AlkPhos-837* TotBili-4.1* ___ 06:20AM BLOOD ALT-175* AST-211* AlkPhos-679* TotBili-2.3* ___ 06:55AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.8 ___ 11:30AM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG MRCP IMPRESSION: 1. Unremarkable MRI. No biliary obstruction, choledocholithiasis, or evidence of acute cholangitis. No morphologic changes of cirrhosis and no suspicious liver lesion. 2. Mild hepatic steatosis. Brief Hospital Course: #Alcoholic hepatitis #Mild AGMA (bicarb 19) #Elevated lipase (120, 2x ULN) Seen last month here for alc hep, now back with recurrence. Transaminitis and elevated bilirubin are likely in the setting of alcohol use however labs are uptrending as of 10 days ago. HBV/HCV unremarkable on last admission. AGMA is c/w element of starvation ketosis and lipase elevation is likely in the setting of chronic alcohol abuse. -LFTs are trending down today -hepatology consulted, appreciate recs, MRCP with no obstruction, ceruloplasmin was checked and WNL, no further work up recommended so far, holding on liver biopsy, ETOH abstinence # Alcohol withdrawal # Alcohol use disorder History of withdrawal on last admission c/b hallucinations and confusion. No h/o seizures or ICU admissions for etOH. Last drink today in the ED today. Endorses mild tremors and anxiety. - did not undergo significant withdrawal, no seizures here - PO thiamine daily - Multivitamin and folic acid - SW following - addiction psych OP appointment - psych also saw him here and continued on his Psych regimen with OP PSych follow up. -plan for outpatient ETOH program Adcare which has been enrolled in from before. He tells us that he is going to go there starting tomorrow morning. ====================== CHRONIC/STABLE ISSUES: ====================== # Hypertension - Continue amLODIPine 10 mg PO DAILY # Hyperlipidemia - holding statin with liver enzymes elevation for now and plan to resume once approved by his PCP or ___. # Anxiety # Depression - continue Zoloft, Seroquel and hydroxyzine PRN. Transitional issues: -Repeat complete metabolic panel within 5 days -Outpatient follow-up with his PCP, ___, psychiatry and follow-up with outpatient ___ rehab program. Total time spent on the discharge process by me personally was greater than 30 minutes, most of which was spent in counseling and discharge coordination. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. HydrOXYzine 25 mg PO Q8H:PRN Anxiety 3. Pravastatin 40 mg PO QPM 4. QUEtiapine Fumarate 50 mg PO QHS 5. Multivitamins 1 TAB PO DAILY 6. Naproxen 250 mg PO Q12H:PRN Pain - Mild 7. Sertraline 100 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Pantoprazole 40 mg PO Q12H Discharge Medications: 1. Thiamine 200 mg PO DAILY RX thiamine HCl (vitamin B1) 100 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. HydrOXYzine 25 mg PO Q8H:PRN Anxiety 6. Multivitamins 1 TAB PO DAILY 7. Naproxen 250 mg PO Q12H:PRN Pain - Mild 8. Pantoprazole 40 mg PO Q12H 9. QUEtiapine Fumarate 50 mg PO QHS 10. Sertraline 100 mg PO DAILY 11. HELD- Pravastatin 40 mg PO QPM This medication was held. Do not restart Pravastatin until evaluated by your PCP or liver clinic and they approve restarting this Discharge Disposition: Home Discharge Diagnosis: Alcoholic hepatitis EtOH abuse EtOH withdrawal Anxiety and depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came in with the intention of quiting alcohol. You were found to have elevated liver enzymes which is though to be secondary to your alcohol use prior to coming in. You were evaluated by hepatology service and psychiatry. He was also seen by social care. Your liver enzymes are starting to improve. You are medically stable for discharge today with outpatient follow-up with AdCare outpatient detox program. He should have repeat labs including complete metabolic panel done within 5 to 7 days as outpatient, your PCP office can order this to monitor your liver enzymes. You have a follow-up with the liver clinic. Please absolutely abstain from alcohol to avoid any further damage to your liver and other problems. We wish you all the best. Followup Instructions: ___
19833978-DS-19	19,833,978	26,636,678	DS	19	2125-10-20 00:00:00	2125-10-28 15:54:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: SIGNIFICANT LABS: =============== ___ 11:38AM BLOOD WBC-3.7* RBC-3.59* Hgb-11.9* Hct-35.9* MCV-100* MCH-33.1* MCHC-33.1 RDW-12.3 RDWSD-45.1 Plt ___ ___ 05:25AM BLOOD WBC-4.4 RBC-3.48* Hgb-11.7* Hct-34.9* MCV-100* MCH-33.6* MCHC-33.5 RDW-11.9 RDWSD-44.1 Plt ___ ___ 11:38AM BLOOD Glucose-90 UreaN-14 Creat-0.9 Na-143 K-4.4 Cl-99 HCO3-23 AnGap-21* ___ 05:25AM BLOOD Glucose-104* UreaN-6 Creat-0.9 Na-138 K-4.2 Cl-97 HCO3-26 AnGap-15 ___ 11:38AM BLOOD ALT-178* AST-348* CK(CPK)-383* AlkPhos-325* TotBili-0.6 ___ 05:25AM BLOOD ALT-114* AST-137* AlkPhos-305* TotBili-0.6 IMAGING/OTHER STUDIES: ==================== Brief Hospital Course: Mr. ___ is a ___ man with history of alcohol use disorder, multiple admissions for alcoholic hepatitis, depression/anxiety presenting with abdominal pain and nausea. # Abdominal pain/nausea: Patient presenting with abdominal pain and nausea in setting of heavy alcohol use. suspect primarily due to alcoholic gastritis. Lipase not elevated and no significant findings on CT a/p. Overall consistent with alcoholic gastritis. Patient resumed on home PPI and counseled on need to refrain from drinking alcohol. # Alcoholic hepatitis: # Alcohol use disorder: Patient currently drinking about 8 nips of vodka per day. DF score 5; thus, no indication for steroids. Patient with extensive work up for alternative etiologies on prior admissions. He met with SW and declined assistance with outpatient programs, but did agree to keep his appointment with Addiction Psychiatry on ___. # Anxiety: # Depression: Patient reported suicidal ideation on admission in setting of self-discontinuing psychiatric medications and resuming alcohol use. Patient denies SI/HI at present. Seen by psychiatry in ED and deemed not to require ___ or sitter. HE was restarted on his home sertraline and quetiapine with plan for close outpatient follow up on ___. # Lactic acidosis: Suspect type B in setting of EtOH use. # Anemia: # Leukopenia: Chronic, stable. Likely secondary to alcohol use and nutritional deficiencies. Resumed vitamins. # Hypertension - Resumed amlodipine # Hyperlipidemia - No longer on a statin TRANSITIONAL ISSUES: ==================== [] of abdominal symptoms fail to improve despite PPI therapy and abstinence from alcohol, then patient may warrant further evaluation with EGD. [] continue to offer support for alcohol cessation. > 30 mins spent coordinating discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. HydrOXYzine 50 mg PO BID:PRN Anxiety 5. Multivitamins 1 TAB PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. QUEtiapine Fumarate 50 mg PO QHS 8. Sertraline 100 mg PO DAILY 9. Thiamine 200 mg PO DAILY 10. Sucralfate 1 gm PO BID Discharge Medications: 1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line Reason for PRN duplicate override: Alternating agents for similar severity RX ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. QUEtiapine Fumarate 50 mg PO QHS 8. Sertraline 100 mg PO DAILY 9. Sucralfate 1 gm PO BID 10. Thiamine 200 mg PO DAILY 11. HELD- HydrOXYzine 50 mg PO BID:PRN Anxiety This medication was held. Do not restart HydrOXYzine until discussed at your upcoming psychiatry visit. Discharge Disposition: Home Discharge Diagnosis: # alcohol use disorder: # alcoholic gastritis: # depression/anxiety: Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege to care for you at the ___ ___. You were admitted with abdominal pain and nausea due to irritation of your stomach from alcohol use. You were started back on your home medications for depression/anxiety as well as your antacid medication to help with your stomach pain. It is extremely important that you refrain from drinking alcohol and follow up with your Addiction psychiatry appointment on ___. You are being discharged with Zofran to take as needed for nausea prior to meals. This medication should not be taken more frequently than every 8 hours (that is ok to use before breakfast and then dinner, skipping lunch, if needed). This medication should not be taken long term. The best treatment for your symptoms will be to abstain from alcohol and to continue your PPI (pantoprazole). We wish you the best in your recovery. Sincerely, Your ___ Team Followup Instructions: ___
19834495-DS-13	19,834,495	21,668,984	DS	13	2141-02-11 00:00:00	2141-02-11 17:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: lymphoma work-up Major Surgical or Invasive Procedure: ___ placement ___ PET/CT ___ History of Present Illness: ___ with no significant chronic medical problems. She went to her PCP ___ ___ with few weeks of severe fatigue, anorexia, wt loss, night sweats who got a CT C/A/P and noted splenomegaly. She was referred to hematology. Labs showed elevated CRP and LDH, along with some atypical lymphocytes. Peripheral cytology was suggestive of B cell lymphoma and she underwent BM biopsy on ___. Now she is referred here for BM biopsy findings of high grade lymphoma, preliminary results. Of note, she was treated for pneumonia in ___. After treatment her URI like symptom improved but fatigue and night sweats persisted and got significantly worse in ___. She also c/o dyspnea on minimal exertion. In ED, her initial vitals were 99.5 ,106, 119/56, 18, 100% RA Tumor lysis labs along with HIV and G6PD were ordered and patient started on NS Continuous at 125 mL/hr for 1000 mL. History obtained with help of her son and daughter in law at bedside. Past Medical History: -Osteoarthritis -Osteopenia - Onset -Localized vitiligo -Vitamin D deficiency -Benign lipomatous tumor -Chronic post-traumatic stress disorder -Sensorineural hearing loss Social History: ___ Family History: No family history of malignancy or blood disorder reported Physical Exam: ADMISSION EXAM: =============== Vital Signs:99.0 BP 119 / 70 87 18 97 RA General appearance: appears fatigued, in no acute distress. Head, eyes, ears, nose, and throat: mild pallor. no icterus. moist mucous membranes. Cardiovascular: Regular rate and rhythm, S1, S2, no audible murmurs. Respiratory: Lungs clear to auscultation bilaterally. Abdomen: Bowel sounds present, soft, nontender, nondistended. Extremities: Warm, without edema. Neurologic: Alert and oriented. non focal. Skin: No rashes. DISCHARGE EXAM: =============== GENERAL: Comfortable, NAD, A/Ox3. HEAD: NC/AT, conjunctiva clear, sclera anicteric, MMM. CARDIAC: S1S2 w/o m/r/g. RESPIRATORY: CTABL. ABDOMEN: Palpable splenic edge, soft, NT, +BS. EXTREMITIES: Warm, trace ___ edema. NEUROLOGIC: Non-focal. SKIN: No rashes. Pertinent Results: ADMISSION LABS: =============== ___ 08:00PM LD(LDH)-920* ___ 08:00PM URIC ACID-5.1 ___ 08:00PM HIV1 VL-NOT DETECT ___ 08:00PM HGB-8.0* ___ 08:00PM RET AUT-1.2 ABS RET-0.03 ___ 07:11PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 07:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-SM* ___ 07:11PM URINE RBC-0 WBC-5 BACTERIA-FEW* YEAST-NONE EPI-0 ___ 07:11PM URINE AMORPH-RARE* ___ 07:11PM URINE MUCOUS-OCC* ___ 06:49PM LACTATE-3.2* ___ 06:19PM GLUCOSE-103* UREA N-15 CREAT-0.7 SODIUM-138 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17 ___ 06:19PM ALT(SGPT)-69* AST(SGOT)-58* LD(___)-995* ALK PHOS-88 TOT BILI-0.8 ___ 06:19PM ALBUMIN-3.3* CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-2.1 URIC ACID-5.2 ___ 06:19PM WBC-5.3 RBC-2.99* HGB-8.7* HCT-26.3* MCV-88 MCH-29.1 MCHC-33.1 RDW-13.4 RDWSD-41.9 ___ 06:19PM NEUTS-75* BANDS-4 LYMPHS-10* MONOS-6 EOS-1 BASOS-1 ATYPS-1* METAS-1* MYELOS-0 NUC RBCS-1* OTHER-1* AbsNeut-4.19 AbsLymp-0.58* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.05 ___ 06:19PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 06:19PM PLT SMR-LOW* PLT COUNT-111* ___ 11:00AM BONE MARROW IPT-DONE ___ 09:45AM UREA N-16 CREAT-0.6 SODIUM-139 POTASSIUM-4.8 ___ 09:45AM estGFR-Using this ___ 09:45AM ALT(SGPT)-71* AST(SGOT)-49* LD(___)-1002* ALK PHOS-90 TOT BILI-0.9 ___ 09:45AM URIC ACID-5.4 IRON-54 ___ 09:45AM calTIBC-202* FERRITIN-661* TRF-155* ___ 09:45AM CRP-156.8* ___ 09:45AM WBC-5.1 RBC-3.19* HGB-9.0* HCT-28.3* MCV-89 MCH-28.2 MCHC-31.8* RDW-13.2 RDWSD-42.0 ___ 09:45AM NEUTS-65 BANDS-1 LYMPHS-14* MONOS-15* EOS-1 BASOS-0 ___ METAS-1* MYELOS-0 OTHER-3* AbsNeut-3.37 AbsLymp-0.71* AbsMono-0.77 AbsEos-0.05 AbsBaso-0.00* ___ 09:45AM HOS-SENT ___ 09:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 09:45AM PLT SMR-LOW* PLT COUNT-119* INTERVAL LABS: ============== ___ 09:45AM BLOOD ALT-71* AST-49* LD(LDH)-1002* AlkPhos-90 TotBili-0.9 ___ 06:19PM BLOOD ALT-69* AST-58* LD(LDH)-995* AlkPhos-88 TotBili-0.8 ___ 08:00PM BLOOD LD(LDH)-920* ___ 06:45AM BLOOD ALT-59* AST-39 LD(LDH)-973* AlkPhos-86 TotBili-1.0 ___ 05:00PM BLOOD ALT-52* AST-37 LD(___)-908* AlkPhos-73 TotBili-1.0 ___ 06:50AM BLOOD ALT-52* AST-32 LD(LDH)-927* AlkPhos-78 TotBili-1.0 ___ 05:07AM BLOOD ALT-39 AST-20 LD(LDH)-721* AlkPhos-69 TotBili-1.0 ___ 05:07AM BLOOD Hapto-207* ___ 05:00PM BLOOD HBV VL-NOT DETECT ___ 08:00PM BLOOD HIV1 VL-NOT DETECT ___ 01:15PM BLOOD HCV Ab-NEG ___ 01:15PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* DISCHARGE LABS: =============== ___ 09:48AM BLOOD WBC-8.9 RBC-2.89* Hgb-8.4* Hct-25.5* MCV-88 MCH-29.1 MCHC-32.9 RDW-13.8 RDWSD-42.8 Plt Ct-81* ___ 09:48AM BLOOD Neuts-89* Bands-0 Lymphs-11* Monos-0 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-7.92* AbsLymp-0.98* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 09:48AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear Dr-OCCASIONAL ___ 09:48AM BLOOD Plt Smr-LOW* Plt Ct-81* ___ 04:48AM BLOOD ___ 05:07AM BLOOD Ret Aut-1.4 Abs Ret-0.03 ___ 09:48AM BLOOD Glucose-112* UreaN-12 Creat-0.5 Na-137 K-4.3 Cl-102 HCO3-27 AnGap-8* ___ 02:59PM BLOOD estGFR-Using this ___ 09:48AM BLOOD ALT-40 AST-12 LD(LDH)-210 AlkPhos-64 TotBili-0.7 ___ 09:48AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.3 UricAcd-2.3* IMAGING: ======== CHEST X-RAY ___: IMPRESSION: Right paratracheal mediastinum appears mildly prominent which could be due to a tortuous aorta, however given history of recent diagnosis of lymphoma, underlying mediastinal lymph nodes are not excluded. Nonurgent chest CT would further assess. CT CHEST WITH CONTRAST ___: 1. No lymphadenopathy within the thorax. 2. No parenchymal consolidation. 3. 5 mm calcification within the right lobe of partially visualized thyroid gland. CT ABDOMEN/PELVIS ___: 1. No abnormally enlarged lymph nodes within the imaged abdomen and pelvis. 2. Top-normal spleen measuring 13.8 cm. CXR ___: There has been interval placement of a right PICC with tip seen overlying the mid SVC. No other change. Lungs remain clear. FDG/PET ___: TECHNIQUE: ISOTOPE DATA: (___) 7.0 mCi ___ FDG; LAB DATA: 137 mg/dL Glucose; CT DLP: 558 mGy-cm. Approximately 1 hour after intravenous administration of F-18 fluorodeoxyglucose (FDG), non-contrast CT images were obtained for attenuation correction and for fusion with emission PET images. (The non-contrast CT images are not used to diagnose disease independently of the PET images.) A series of overlapping emission PET images was then obtained. The area imaged spanned the region from the skullbase to the mid thighs. Computed tomography (CT) images were co-registered and fused with emission PET images to assist with the anatomic localization of tracer uptake. The determination of the site of tracer uptake seen on PET data can have important implications regarding the significance of that uptake. FINDINGS: HEAD/NECK: No abnormal foci of FDG avidity the in the head or neck. No cervical lymphadenopathy. CHEST: No abnormal foci of FDG avidity in the chest. There is no mediastinal, hilar, or axillary lymphadenopathy. A PICC terminates at the superior cavoatrial junction. Mild dependent atelectasis. Trace left pleural effusion. ABDOMEN/PELVIS: 1.7 cm short axis celiac/pyloric lymph nodes and a 1.2 cm short axis portocaval lymph node demonstrate an SUV max of 10.64. A 1.2 cm portal caval lymph node and aortocaval lymph nodes measuring 7 and 8 mm short axis demonstrate an SUV max of 5.5. No mesenteric or pelvic lymphadenopathy. The spleen demonstrates diffuse FDG avidity with an SUV max of 8.5. The spleen is enlarged, measuring up to 14.2 cm. MUSCULOSKELETAL: Diffuse osseous FDG avidity with no focal lesions identified. Physiologic uptake is seen in the brain, myocardium, salivary glands, GI and GU tracts, liver and spleen. IMPRESSION: FDG avid retroperitoneal lymphadenopathy, FDG avid splenomegaly, and diffuse osseous FDG avidity are compatible with lymphoma. LYMPHOMA WORK-up: ================== Procedure date Tissue received Report Date Diagnosed by ___ ___. ___ DIAGNOSIS: FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: Kappa, Lambda, and CD antigens 2,3,4,5,7,8,10,11c,19,20,23,34,38,45,and 56. RESULTS: 10-color analysis with linear side scatter vs. CD45 gating is used to evaluate for leukemia/lymphoma. Approximately 74.0% of total acquired events are evaluable nondebris event. The viability of the analyzed non-debris events, done by 7-AAD is 98.1%. CD45-bright, low side-scatter gated lymphocytes comprise 19.1% of total analyzed events. B cells comprise 17.5% of lymphoid gated events. B cells demonstrate monoclonal lambda light chain restriction. They coexpress pan-B cell markers CD19, CD20 and CD23 (subset). They do not express any other characteristic antigens including CD5,10,CD38 and 11c. T cells comprise 59.3% of lymphoid gated events and express mature lineage antigens (CD3, CD5, CD2, and CD7). A minor subset (9.17%) of T cells shows dim/variable loss of CD7 (nonspecific finding). T cells have a normal CD3:CD8 ratio of 2.88 (usual range in blood 0.7-3.0). There is a population of double negative (CD4 negative/CD8 negative) T-cells comprise 3.6% of CD3 positive cells. Approximately 8.5% of CD3 positive T-cells coexpress CD56. CD56 positive, CD3 negative natural killer cells represent 6.2% of gated lymphocytes. They coexpress CD2, CD7 and CD8 (subset). INTERPRETATION Immunophenotypic findings consistent with involvement by a CD5 negative, CD10 negative B-cell lymphoma. Given the patient's clinical finding of isolated splenomegaly, Splenic Marginal zone lymphoma is high in the differential. Correlation with clinical, imaging,and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. SPECIMEN SUBMITTED: Immunophenotyping - bone marrow aspirate Procedure date Tissue received Report Date Diagnosed by ___ ___. ___ Previous biopsies: ___ BONE MARROW, BIOPSY, CORE ___ immunophenotyping: peripheral blood DIAGNOSIS: FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: Kappa, Lambda, ___. ___, CD138, and CD antigens 2,3,4,5,7,8,10,11c,13,14,16,19,20,23,33,34,38,45,56,64, and 117. RESULTS: 10-color analysis with linear side scatter vs. CD45 gating is used to evaluate for leukemia/lymphoma. Approximately 85.6% of total acquired events are evaluable nondebris events. The viability of the analyzed nondebris events done by 7-AAD is 97.5%. CD45-bright, low side-scatter gated lymphocytes comprise 15.6% of total analyzed events. B cells comprise 30.7% of lymphoid-gated events. A subset of B cells (60%) demonstrate monoclonal kappa light chain restriction. They express pan-B cell markers CD20 along with CD5, CD10 (subset). They do not express CD19 or any other characteristic antigens including CD23, CD11c and CD38. The remainder B-cell (approximately 40%)show marked lambda light chain predominance, they are positive for CD19, CD20 and are negative for CD5, CD10, CD23, CD38 and CD11c. CD45 dim, CD19 positive B cell population is identified that coexpresses CD10 with variable CD20 and absent surface immunoglobulin, immunophenotypically consistent with hematogones (0.3%). T cells comprise 34.9% of lymphoid gated events and express mature lineage antigens (CD3, CD5, CD2, and CD7). A minor subset (4.8%) of T cells shows dim/variable loss of CD7 (nonspecific finding). T cells have a CD4:CD8 ratio of 0.88(usual range in blood 0.7-3.0). There is a population of double negative (CD4 negative/CD8 negative) T-calls comprise 13% of CD3 positive cells. Approximately 16.7% of CD3 positive T-cells coexpress CD56. CD56 positive CD3 negative natural killer cells represent 9.6% of gated lymphocytes. They coexpress CD2, CD7 and CD8 (subset). No abnormal events are identified in the "blast gate." CD34 positive blasts are 0.8% of the total analyzed events. Plasma cells comprise 0.24% of the total analyzed events, are polytypic by kappa and lambda cytoplasmic light chain staining. INTERPRETATION Immunophenotypic findings consistent with involvement by CD5 positive, kappa restricted B-cell lymphoma. In addition, a smaller population of lambda predominant, CD5 negative B-cells were detected. Given the SPEP finding of IgM lambda monoclonal band, this is suggestive of involvement by a second lymphoma. Correlation with clinical, morphologic (see separate pathology ___-___) and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. Review of the accompanying pathology paperwork indicates splenomegaly and non-Hodgkin lymphoma. DNA quality was optimal. Excellent gene coverage was achieved which passed our internal quality checks. MLL2 (KMT2D) encodes a histone methyltransferase that methylates the Lys-4 position of histone H3. MLL2 mutations are seen commonly in a variety of non-Hodgkin lymphomas including transformed follicular lymphoma, diffuse large b-cell lymphomas, and other aggressive non-Hodgkin lymphomas such as mantle cell lymphoma. MLL2 mutations are also seen in nodal marginal zone lymphoma. Consideration may be given to targeted therapies such as hypomethylating agents and/or HDAC inhibitors, in an investigational context, as clinically appropriate. CARD11 protein is a member of the CARD protein family, which is defined by carrying a characteristic caspaseassociated recruitment domain (CARD). This protein has a domain structure similar to that of CARD14 protein. The CARD domains of both proteins have been shown to specifically interact with BCL10, a protein known to function as a positive regulator of cell apoptosis and NF-kappaB activation. When expressed in cells, this protein activated NF-kappaB and induced the phosphorylation of BCL10. CARD11 is involved in the costimulatory signal essential for T-cell receptor (TCR)- mediated T-cell activation. Its binding to DPP4 induces T-cell proliferation and NF-kappa-B activation in a T-cell receptor/CD3-dependent manner. CARD11 mutations have been described in various B-cell non-hodgkin lymphomas including follicular lymphoma, mantle cell lymphoma, and diffuse large b-cell lymphoma. The FBXW7 encodes a member of the F-box protein family which is characterized by an approximately 40 amino acid motif, the F-box. The F-box proteins constitute one of the four subunits of ubiquitin protein ligase complex called SCFs (___), which function in phosphorylation-dependent ubiquitination. This protein binds directly to cyclin E and probably targets cyclin E for ubiquitin-mediated degradation. Mutations in FBXW7 have been described in a variety of solid tumor and hematologic malignancies including lymphoblastic leukemia and non-Hodgkin lymphomas. In summary, this genomic signature suggests an aggressive clinical course and can be seen in a number of hematologic malignancies including non-Hodgkin lymphomas. Therapies are in various stages of clinical development directed against the identified genomic aberrations, and may be available as clinically indicated and appropriate. The signature can further be utilized to monitor the patient's disease course over time. Complete interpretation requires clinical correlation with histomorphologic and other laboratory testing results. Brief Hospital Course: PATIENT SUMMARY: ================ Ms. ___ is a ___ w/ no significant PMH admitted for expedited workup of fatigue, anorexia, weight loss & night sweats, found on peripheral cytology to have B cell lymphoma w/ BM biopsy showing CD5+ DLBCL w/ gain of BCL2, BCL6, and MYC, now receiving C1 of EPOCH. ACUTE ISSUES: ============= # High Grade B-Cell Lymphoma New diagnosis. Patient presented with splenomegaly, anemia, thrombocytopenia. Symptoms seem to have been ongoing for about 4 months and worsened over the past 2 months leading up to admission. Bone marrow biopsy consistent with high grade B-cell lymphoma. Immuno-phenotyping findings consistent with involvement by a CD5 negative, CD10 negative B-cell lymphoma. PET/CT showed FDG avid retroperitoneal lymphadenopathy, FDG avid splenomegaly, and diffuse osseous FDG avidity compatible with lymphoma. No evidence of TLS. LDH remained elevated though improved over the course of her hospitalization. The patient was started on high dose prednisone prior to initiating DA-EPOCH C1D1 on ___ and received rituximab ___. Anemia and thrombocytopenia were treated supportively. No other symptoms occurred and the patient remained largely asymptomatic. # ?Chronic hepatitis B: # Hepatitis B cAb Positivity: We started entecavir 0.5mg QD. CODE: FULL ========== CONTACT: ========== Son: ___ ___, Secondary contact: Daughter in law: ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Multivitamins Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. Acyclovir 400 mg PO Q12H RX acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 2. Allopurinol ___ mg PO DAILY RX allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 3. Entecavir 0.5 mg PO DAILY RX entecavir 0.5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Filgrastim-sndz 300 mcg SC Q24H RX filgrastim-sndz [Zarxio] 300 mcg/0.5 mL 300 mcg SC Daily Disp #10 Syringe Refills:0 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 6. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: ======== High Grade B-Cell Lymphoma SECONDARY: ========== Anemia Hepatitis B Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were in the hospital for further testing, including imaging and laboratory studies, to help confirm the diagnosis of lymphoma. WHAT HAPPENED IN THE HOSPITAL? - You had a CT scan of your chest, abdomen, and pelvis. This showed an enlarged spleen. - You had a PET scan. This showed lymphoma in your bones, lymph nodes and spleen. - You had a PICC line placed in order to give you medications and draw your blood more easily. - You were given steroids to help treat the lymphoma. - You were then started on a chemotherapy regimen called EPOCH-R in order to treat the lymphoma. - Your blood tests were monitored closely after starting the chemotherapy. WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL? - Follow up with ___ after your first cycle of EPOCH. You will get your future cycles of chemotherapy at ___. - Please continue to take all of your medications as prescribed. We wish you the best, Your ___ Care Team Followup Instructions: ___
19834631-DS-12	19,834,631	25,030,106	DS	12	2140-06-03 00:00:00	2140-06-03 14:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cellulitis Major Surgical or Invasive Procedure: R IJ central line (peripheral access was difficult to obtain) History of Present Illness: Mr. ___ is a ___ with PMH significant for IVDU (Heroin) and Hep C who presented to the ___ ED with Right arm burning pain, redness, and swelling after injecting into his R wrist on ___. He has noted increasing pain and erythema for the 4 days prior to admission. He was seen at ___ on ___, and was told to return to the ED if his redness and swelling expanded or pain worsened. He was discharged on ___ to ___ for detox. On ___, at ___, he was started on Keflex and Bactrim, but the redness increased in size. His pain was worse when he moved his arm. He was also receiving Methadone at ___ for opiate withdrawal. He does not lick his needles. He uses clean needles that he buys from the store and does not share needles. Injects only in UE, not in groin or ___. Last heroin use was ___. Denied fevers, chills, night sweats, weight loss, numbness, tingling, CP/SOB/palpitations, abdominal pain, N/V/C/D, dysuria. In the ED initial vitals were: 99.7 94 ___ 98% - Labs were significant for WBC 8.3, lactate 1.0, and positive urine methadone screen. Neg UA. STox neg other than for benzo (given in ED as below) - Patient was given PO Percocet x 2, PO Diazepam 10mg x2, IV Dilaudid 0.5mg, IV Vancomycin 1g, and 1L NS. On the floor, he was hemodynamically stable and noting RUE pain, swelling, redness. Otherwise without complaint. Past Medical History: IVDU - heroin, has had numerous withdrawals with seizures before, last episode was ___. Polysubstance abuse - Benzos, heroin Hepatitis C Depression PAST SURGICAL HISTORY: Prior I&D for "cellulitis", RUE Social History: ___ Family History: Noncontributory Physical Exam: Admission Physical Exam: Vitals: 97.5 70 115/73 16 100% RA GENERAL: NAD HEENT: Healing scabs on R posterior skull, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, nl S1,S2, no m/r/g LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Soft, NT/ND, no HSM, BS+, no guarding or rebound tenderness EXTREMITIES: WWP. 2+ ___ pulses. No cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: A&Ox3. CN II-XII intact. Motor and sensation intact grossly in all 4 extremities. SKIN: RUE - R forearm erythema, edema, and induration that is TTP and worst around the dorsolateral wrist near ulnar head. SILT M/R/U. Able to squeeze finger. No obvious trackmarks noted. No other rashes. Minimal excoriations on BLE. . Discharge Physical Exam: Vitals: Tm 99.1, 89-120/48-76, 90-101, 18, 95% RA I/O: 2 BMs yesterday GENERAL: Laying bed comfortably, in NAD CARDIAC: RRR, nl S1,S2, no m/r/g LUNG: CTAB ABDOMEN: Soft, mild R-sided abd TTP EXTREMITIES: warm without edema SKIN: R wrist looks normal Pertinent Results: Admission Labs: ___ 05:20AM WBC-8.3 RBC-3.69* HGB-11.8* HCT-34.4* MCV-93# MCH-32.0 MCHC-34.3 RDW-14.2 ___ 05:20AM NEUTS-62.5 ___ MONOS-8.8 EOS-1.9 BASOS-0.2 ___ 05:20AM GLUCOSE-112* UREA N-6 CREAT-0.8 SODIUM-137 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 ___ 05:33AM LACTATE-1.0 ___ 03:00AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS ___ 05:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG ___ 05:20AM ALT(SGPT)-26 AST(SGOT)-19 ALK PHOS-43 TOT BILI-0.3 ___ 02:53PM CRP-30.8* ___ 02:53PM BLOOD SED RATE 20 . >> Micro: Blood Culture, Routine (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. ___ 9:49 am STOOL C. difficile DNA amplification assay (Final ___: Positive for toxigenic C. difficile by the Illumigene DNA amplification. . >> Imaging: ___ ED US - RUE: no drainable fluid collections ___ CXR: Right IJ terminates at the superior cavoatrial junction. No acute cardiopulmonary process. ___ R Wrist plain films: No acute fracture or dislocation. Brief Hospital Course: Mr. ___ is a ___ with PMH significant for IVDU (Heroin), daily benzo use, and Hep C who presented to the ___ ED with Right arm pain after injecting drugs to the site, treated with IV antibiotics, course complicated by c. diff diarrhea. . # Right wrist cellulitis: Patient developed burning pain, redness, and swelling after injecting into his R wrist on ___. He noted increasing pain and erythema for the 4 days prior to admission. Came on ___ from ___ for detox. On ___, at ___, he was started on Keflex and Bactrim, but the redness increased in size so he was transferred for IV antibiotics and Hand surgery eval. Hand surgery did not feel he needed surgical intervention. He was seen by OT and the hand was splinted. Pt put on Vanc/unasyn ___, narrowed to augmentin/bactrim ___ to ___. Blood cultures were negative. Pain was controlled with standing tylenol/ibuprofen, as well as PO morphine, which was gradually tapered off. . # C.diff diarrhea: Developed watery diarrhea ___ per day) in setting of broad spectrum antibiotics for wrist cellulitis. C.diff pcr was positive, no leukocytosis or lactatemia, abdominal exam was benign. He was started on flagyl ___ and changed to PO vanc on ___ in the setting of persistent diarrhea. Pt to continue PO vanc until ___ (10d after finishing cellulitis antibiotics). . # Difficult IV access: Due to inability to secure IV access in the ED patient received a right IJ central line in the ED. This was discontinued when IV antibiotics were completed and his central line was removed as soon as he was felt to be stable from a c.diff stand point. . # Polysubstance abuse: He continued taper off of ativan successfuly but did require high doses of narcotics for adequate pain control. He was seen by the addiction specialist nurse and was seen by psychiatry. PO morphine for pain control tapered throughout admission Pt was put on a ___ temporarily for hopelessness/depression; pt was cleared for discharge by psych on ___ and pt planned to go to the court to obtain a section 35 on discharge. . TRANSITIONAL ISSUES: - Pt to continue PO Vanc through ___. Pt counseled on the importance of completing course - Pt counseled about potential for relapse and that tolerance to opiates has decreased and so prior dose of heroin has high potential to be fatal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. BusPIRone 20 mg PO BID 3. BuPROPion 75 mg PO BID 4. Lorazepam 1 mg PO QID 5. Cephalexin 500 mg PO Q8H 6. Sulfameth/Trimethoprim DS 1 TAB PO TID 7. DiCYCLOmine 20 mg PO QID 8. LOPERamide 2 mg PO QID:PRN diarrhea 9. Catapres (cloNIDine HCl) 0.1 mg oral Q 6hr PRN agitation Discharge Medications: 1. BuPROPion 75 mg PO BID RX bupropion HCl 75 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 2. BusPIRone 20 mg PO BID RX buspirone 10 mg 2 tablet(s) by mouth twice a day Disp #56 Tablet Refills:0 3. Gabapentin 800 mg PO TID RX gabapentin 400 mg 2 capsule(s) by mouth three times a day Disp #84 Capsule Refills:0 4. Vancomycin Oral Liquid ___ mg PO Q6H Last day ___. RX vancomycin 125 mg 1 capsule(s) by mouth every 6 (six) hours Disp #20 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Cellulitis, C diff colitis Secondary: Intravenous drug use Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. As you know, you were admitted to the inpatient Medicine service for cellulitis (skin infection) of your right wrist. You were treated with IV antibiotics and the hand surgeons saw you. They did not think you needed surgery, and your hand improved with antibiotics alone, and with exercises from the occupational therapists. While you were here you developed a bacterial diarrhea called "clostridium difficile" which can happen after taking antibiotics. You should continue oral vancomycin for 10 days total. Your last day of oral vancomycin will be ___. It is important that you finish this course of antibiotics as this infection can be very serious and life-threatening. The psychiatry team also followed you in the hospital and provided you resources for your depression and work towards sobriety from IV drugs. We wish you the best of luck with your sobriety. Please remember that your opiate tolerance has decreased and so if you relapse, previous doses of heroin may be fatal. Please keep your narcan kit available to your family. Contact information for contact info for ___ Emergency Services Team (BEST) is ___. Followup Instructions: ___
19835208-DS-19	19,835,208	23,279,850	DS	19	2145-07-29 00:00:00	2145-07-29 17:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. ___ is a ___ male with a history of IVDU (last used ___ years ago, on methadone), depression, anxiety and bipolar disorder who was transferred from ___ with jaundice and found to have acute hepatitis. He reports that on ___, he ate out at a restaurant and upon arriving at home, had sudden onset of intermittent, sharp right upper quadrant abdominal and epigastric pain. Later, he noticed dark urine, pale loose stools and scleral icterus. He went to see his primary care doctor who got initial lab studies and sent him to ___. Patient reports that he has ongoing intermittent right upper quadrant abdominal pain, described as sharp without clear exacerbating or relieving factors, and with occasional radiation to the epigastric and back. Has taken ibuprofen ("about ___ pills twice"), and denies recent acetaminophen use. No other new drug exposures. Reports that his stool has been loose, light gray in color without blood or mucous, and his urine has been dark. His wife noticed his eyes were yellow. He notes some headache and dizziness at the time of symptom onset, but these have since resolved. He has a long standing history of opioid use disorder and reports intravenous drug use from the age of ___, quitting about ___ years ago. Since that time, he denies further IVDU. He says he has had annual Hep C screening, as recent as 9 months ago, and these studies have all been negative. He further denied new sexual partners (has been with his wife for ___ years) or new tattoos. He has not had any blood transfusion, has not consumed mushrooms or shellfish, has not swum in rivers or streams, or traveled outside of ___ recently. He has never traveled outside of the country. He further denied a history of chest pain, shortness of breath, urinary symptoms, hematuria, hematochezia, melena, muscle or joint pains. In the ED, initial VS were: T 98.0F HR 67 BP 114/79 RR 19 O2 100% RA Exam notable for: HEENT: Scleral icterus Abdominal: Tender to palpation in RUQ. No rebound, no guarding Neuro: No asterixis Labs showed: WBC 5.6 Hgb 12.8 ___: 10.4 PTT: 30.5 INR: 1.0 ALT:1313 AST:973 AlkPhos:203 TotBili:8.1 Albumin:3.5 HBsAg:NEG HBsAb:NEG HBcAb:NEG IgM HAV:NEG HCV Ab:POS HCV VL: PND Lactate:1.2 ASA:NEG Ethanol:NEG Acetmnp:NEG Bnzodzp:NEG Barbitr:NEG Tricycl:NEGo Imaging: RUQ U/S (OSH), Dupplex abdominal ultrasound Normal hepatic parenchyma, patent portal vein, no ascites, no cholelithiasis or acute cholecystitis, non-specific mildly prominent CBD but appears to taper towards the pelvic hilum. No portal venous thrombosis, Budd-Chiari. Patent hepatic vasculature. Consults: Hepatology was consulted and finds the patient's presentation consistent with acute liver injury, potentially secondary to acute HCV, no evidence to suggest ischemia, Budd-Chiari, acetaminophen, biliary obstruction. Serologies for autoimmune hepatitis pending. Transfer VS were: T 98.6 HR 57 BP 127/81 RR 18 O2 99% RA On arrival to the floor, patient reports feeling improved. He continues to have intermittent abdominal pain, ___ at its worst and sharp in nature. He notes having his first formed stool, which was normal in color and his urine is no longer dark. He currently feels well otherwise, and specifically denied headache, dizziness or confusion. Past Medical History: Opiate Use Disorder on Methadone Depression Anxiety Bipolar disorder Acid reflux Social History: ___ Family History: No family history of liver disease Physical Exam: ADMISSION: VS: T 98.2 129/77 HR 68 R 18 O2 98 GENERAL: NAD, lying comfortably in bed HEENT: AT/NC, EOMI, PERRL, mild scleral icterus NECK: supple HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, faint diffuse expiratory wheezes, no rales or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, tender to palpation in epigastric region and RUQ, no tenderness to percussion, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. No asterixis DISCHARGE: GENERAL: NAD, lying in bed HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: nondistended, non-tender to palpation, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, No asterixis Pertinent Results: ADMISSION: ___ 05:18AM BLOOD WBC-5.6 RBC-4.52* Hgb-12.8* Hct-38.5* MCV-85 MCH-28.3 MCHC-33.2 RDW-16.2* RDWSD-50.5* Plt ___ ___ 06:33AM BLOOD ___ PTT-30.5 ___ ___ 05:18AM BLOOD Glucose-102* UreaN-13 Creat-0.8 Na-144 K-4.3 Cl-106 HCO3-26 AnGap-12 ___ 05:18AM BLOOD ALT-1313* AST-973* AlkPhos-203* TotBili-8.1* ___ 07:14PM BLOOD ALT-1349* AST-962* LD(LDH)-376* AlkPhos-198* TotBili-8.3* DirBili-6.9* IndBili-1.4 ___ 07:14PM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.5 Mg-1.6 ___ 07:10AM BLOOD calTIBC-356 Ferritn-644* TRF-274 ___ 07:10AM BLOOD HAV Ab-POS* IgM HAV-NEG ___ 05:18AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG ___ 05:18AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 05:18AM BLOOD ___ ___ 05:18AM BLOOD IgG-734 IgA-107 IgM-270* ___ 07:10AM BLOOD HIV Ab-NEG ___ 05:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:18AM BLOOD Acetmnp-NEG ___ 12:50PM BLOOD HIV1 VL-PND ___ 05:18AM BLOOD HCV VL-6.1* ___ 05:46AM BLOOD Lactate-1.2 DISCHARGE: ___ 06:58AM BLOOD WBC-6.4 RBC-4.74 Hgb-13.5* Hct-40.6 MCV-86 MCH-28.5 MCHC-33.3 RDW-16.8* RDWSD-51.7* Plt ___ ___ 06:58AM BLOOD ___ ___ 06:58AM BLOOD Glucose-76 UreaN-12 Creat-0.9 Na-143 K-4.3 Cl-102 HCO3-31 AnGap-10 ___ 06:58AM BLOOD ALT-1045* AST-606* LD(LDH)-290* AlkPhos-202* TotBili-6.8* ___ 06:58AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.8 IMAGES: RUQUS ___ FINDINGS: Hepatic parenchyma is within normal limits and the contour of the liver is smooth, unchanged from prior. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 20 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent, with appropriate waveform. Right, middle and left hepatic veins are patent, with appropriate waveforms. Splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: Patent hepatic vasculature. Brief Hospital Course: Mr. ___ is a ___ y/o male with a history of IVDU (last used ___ years ago, on methadone), depression, anxiety and bipolar disorder who was transferred from ___ with jaundice and found to have acute hepatitis. #Acute Livery Injury #Hepatitis C Presented with acute liver injury, transaminitis (1000s), and RUQ pain with normal INR and no hepatic encephalopathy. HEP C positive AB with Viral Load 6.1. Other workup was negative including: acetaminophen, HAV IgM, HbsAg, AMA, ___. Ferritin was 644. HIV Ab negative. IgM mildly elevated, most likely in the setting of acute inflammation. Hepatology was consulted and felt that his liver injury was in the setting of acute Hep C infection. He should ___ with the ___ for consideration of HCV treatment. Will require Hep B immunization in the outpatient setting. # Opiate Use Disorder on Methadone - Continued methadone 50 mg daily, give in liquid form #Depression - Continued fluoxetine #Anxiety - Held clonazepam given hepatic clearance - Started lorazepam #Bipolar disorder - Continued aripiprazole #Acid reflux - Continued omeprazole 20mg daily TRANSITIONAL ISSUES: - ___ with the ___ consideration of HCV treatment. - Will require Hep B immunization in the outpatient setting. - Switched from clonazepam to lorazepam in the setting of acute liver injury, ___ in the outpatient setting ___ checked) - Studies pending at discharge should be followed-up in clinic: -HIV 1 Viral Load -Microbiology -CMV IgG ANTIBODY; CMV IgM ANTIBODY -___ VIRUS VCA-IgG AB; EBV EBNA IgG AB; ___ VIRUS VCA-IgM AB -BLOOD CULTURE #CODE: Full (presumed) #CONTACT: ___ (wife) ___ Billing: greater than 30 minutes spent on discharge counseling and coordination of care Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methadone 50 mg PO DAILY 2. Amphetamine-Dextroamphetamine 30 mg PO TID 3. ClonazePAM 1 mg PO TID 4. ARIPiprazole 10 mg PO DAILY 5. FLUoxetine 20 mg PO DAILY 6. Omeprazole 20 mg PO DAILY Discharge Medications: 1. LORazepam 0.5 mg PO TID:PRN anxiety RX lorazepam 0.5 mg 1 tablet by mouth three times a day Disp #21 Tablet Refills:*0 2. Amphetamine-Dextroamphetamine 30 mg PO TID 3. ARIPiprazole 10 mg PO DAILY 4. FLUoxetine 20 mg PO DAILY 5. Methadone 50 mg PO DAILY 6. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: #Acute Hepatitis C #Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___ because you had inflammation of your liver. WHILE YOU WERE HERE: - We found that your liver damage was likely due to hepatitis C virus - Your liver blood tests started to improve WHEN YOU GO HOME: - Continue all your medications as directed - ___ with the listed doctors - Do not take any Tylenol - Do not take any more Clonazepam, we gave you a prescription for lorazepam instead, which is better handled by the liver We wish you the best, Your ___ Care Team Followup Instructions: ___
19835506-DS-13	19,835,506	24,336,052	DS	13	2166-12-28 00:00:00	2166-12-28 16:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / carboplatin / ciprofloxacin / Keflex Attending: ___. Chief Complaint: R hip pain Major Surgical or Invasive Procedure: R hip TFN ___, ___ History of Present Illness: ___ female with past medical history significant for ovarian cancer stage IV with metastasis to lungs and peritoneum (on taxol/cabo weekly treatment), recurrent pulmonary embolus (on Lovenox) SBO due to metastasis, had an unwitnessed fall on ___ has suffered from right intertrochanteric femur fracture. She was taken to the outside hospital and the diagnosis was made that hospital. The trauma workup for head injuries or other injuries were negative. Since the ___ medical management has been done at ___ ___ patient wanted to be transferred to this hospital for further management of her fracture. Orthopedic trauma was consulted for above finding Past Medical History: ovarian cancer stage IV with metastasis to lungs and peritoneum (on taxol/cabo weekly treatment), recurrent pulmonary embolus (on Lovenox) SBO due to metastasis HEALTH MAINTENANCE COLONIC ADENOMA COLORECTAL CANCER DIVERTICULOSIS INTERNAL HEMORRHOIDS OVARIAN CANCER LOW BACK PAIN RADIATING DOWN RIGHT LEG TO THE TOES Social History: ___ Family History: NA Physical Exam: R lower extremity: - Skin intact - dressing c/d/i - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R hip fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for R hip TFN, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics. She was resumed on her therapeutic home lovenox dose on POD1. The rest of the patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. On post-operative, Day 2, she complained of severe lateral chest wall pain that tender to palpation over the lateral chest wall, and thought to be rib contusion. There were no clinical evidence including stable vital signs that remained unchanged. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on her home therapeutic lovenox dose for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 90 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 2. ALPRAZolam 0.25 mg PO QHS:PRN anxiety Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Lidocaine 5% Patch 1 PTCH TD QAM Apply to lateral chest wall 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg ___ tablet(s) by mouth every four to six hours Disp #20 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. ALPRAZolam 0.25 mg PO QHS:PRN anxiety 8. Enoxaparin Sodium 90 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R hip fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - weight bearing as tolerated, affected extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please continue your home therapeutic lovenox daily WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: - weight bearing as tolerated right lower extremity Treatment Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Followup Instructions: ___
19835539-DS-13	19,835,539	20,329,417	DS	13	2128-05-07 00:00:00	2128-05-07 15:53:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ciprofloxacin Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ woman with an approximate 35+ pack year history of tobacco use, quit in ___, with very severe COPD and radiographic emphysema, FEV1 0.49, 30% predicted with chronic respiratory failure and oxygen 3 L equirement home who presents with exertional SOB last ___ days. She started prednisone 40 mg yesterday per her pulmonologist. . Her story begins about three weeks ago; she noticed a cough without much productive sputum, and has been seen by urgent care and her pulmonary physican. She has gotten a 5 day course with a Z-pack, and a two week course with Cefpodoxime. When she saw her pulmoologist on the ___, her had prescribed Cefpodoxime; when she endorsed a failrue to improve, he started her on 40 mg of Prednisone yesterday, but with a plan to increased to 60 mg Prednisone today. Per report, a CXR on ___ did not reveal any PNA. . She presents today because her shortness of breath has been getting worse, although she has no change in her basline O2 requirement of 3 L. Today she could not even take a shower, and her daughter found her at home sitting 5 the table basically unable to get up and walk around is because she was finding it difficult to breathe. . Of note, she has had a prior ECHO did not reveal any evidence of cor pulmonale. She also has a left lower lobe supradiaphragmatic nodule most prominent, but stable since at least ___. . In the ED, initial VS 97.9 103 136/83 18 100%. On transfer, she was 97.9, 96, 16, 111/65, 99%ra. Labs were unremarkable, with a negative U/A, negative tropinin x 1, negative BNP, and normal WBC count. She did have a CXR which showed an opacity suggesting pneumonia in the left mid to lower lung. Her EKG showed Q waves inferiorly, which were apparently not new since at least ___. She has a NSR, without other ST changes. . She was given Azithromycin 500 mg IV x 1, CeftriaXONE 1 g IV, Albuterol and ipratroprium nebs, and Aspirin 324 mg PO ONCE. . She endorses a cough of increasing frequency, without blood, but productive of yellow sputum. She also endorses some increased urinary frequency. Past Medical History: COPD uterine prolapse lung nodules thoracic compression fracture colon and rectal polyps diverticulosis hemorrhoids hypothyroidism osteoporosis neuropathy macular degeneration asthma humeral neck fracture Social History: ___ Family History: Noncontributory Physical Exam: PHYSICAL EXAM ON ADMISSION: VS - Temp 98.3 BP 159/68 HR 103 RR 20 98% 3L GENERAL - Alert, interactive, in NAD HEENT - PERRLA, dry MM HEART - RRR, nl S1-S2, no MRG LUNGS - very poor air movement bilaterally, unable to appreciate any evidence of consolidation, bilateral inspiratory and expiratory wheezes ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP NEURO - awake, A&Ox3, CNs II-XII grossly intact . PHYSICAL EXAM ON DISCHARGE: VS - Temp 97.7 BP 114/70 HR 86 RR 20 100% 3L GENERAL - Alert, interactive, in NAD HEENT - PERRLA, moist MM HEART - RRR, nl S1-S2, no MRG LUNGS - reduced air movement with prolonged expirations, but no crackles and only very faint expiratory wheezes ABDOMEN - NABS, soft/NT/ND EXTREMITIES - WWP, no c/c/e NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ___ 07:40PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM ___ 07:40PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 ___ 07:10PM GLUCOSE-155* UREA N-19 CREAT-0.7 SODIUM-138 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-28 ANION GAP-16 ___ 07:10PM cTropnT-<0.01 ___ 07:10PM proBNP-147 ___ 07:10PM CALCIUM-10.0 PHOSPHATE-3.4 MAGNESIUM-2.2 ___ 07:10PM WBC-7.9 RBC-4.78 HGB-14.9 HCT-44.9 MCV-94 MCH-31.2 MCHC-33.2 RDW-12.9 ___ 07:10PM NEUTS-88.5* LYMPHS-10.2* MONOS-0.8* EOS-0.1 BASOS-0.3 ___ 07:10PM PLT COUNT-333 . ___ 06:35AM BLOOD WBC-10.2 RBC-4.41 Hgb-13.0 Hct-41.5 MCV-94 MCH-29.5 MCHC-31.4 RDW-13.0 Plt ___ ___ 06:35AM BLOOD Neuts-63.2 ___ Monos-6.5 Eos-0.1 Baso-0.2 ___ 06:30AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-143 K-4.4 Cl-100 HCO3-38* AnGap-9 ___ 06:30AM BLOOD Calcium-10.0 Phos-3.9 Mg-2.2 . ___ 06:35AM BLOOD THEOPHYLLINE-4.5 mg/L (range ___ mg/L) ___ 06:25AM BLOOD THEOPHYLLINE-4.2 mg/L (range ___ mg/L) . EKG: EKG showed Q waves inferiorly, which were apparently not new since at least ___. She has a NSR at 90, without other ST changes. . STUDIES: CXR: The heart is normal in size. The aortic arch is partly calcified. The lungs are hyperinflated. The mediastinal and hilar contours are otherwise unremarkable. Slight subpleural scarring is noted at each lung apex. There is no pleural effusion or pneumothorax. There is patchy opacity projecting over the left mid to lower lobe suggesting pneumonia, not well seen on the lateral view but suspected to reside primarily in the left lower lobe but perhaps involving the lingula. Brief Hospital Course: ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient presented with dyspnea in the setting of having recently been treated for pneumonia with antibiotics, but having only taken one or two doses of steroids. On review of her chest x-ray with her pulmonologist, Dr. ___ was decided that she was unlikely to have a recurrent or partially treated pneumonia, so antibiotics were stopped and she was placed on a prednisone taper in addition to her usual home medications. Her dyspnea improved somewhat and by discharge she was closer to, but not at, her baseline level of dyspnea. She was also started on theophylline 200 mg PO daily, but this may have caused her to have several episodes of tachycardia, so it was stopped. Theophylline levels eventually came back subtherapeutic, making it perhaps less likely that this drug was responsible. She was discharged with a nebulizer for levalbuterol treatments to use as an alternative to her levalbuterol inhalers, since she was reluctant to only use the nebulizer due to the additional time involved in treatments. . ELEVATED BICARBONATE: The patient's bicarbonate was initially normal but rose into the mid to high ___. According to Atrius records, this is near her baeline. It is likely, given her COPD, that she retains CO2 and has a chronic respiratory acidosis with metabolic compensation. . HYPOTHYROIDISM: Continued home levoxyl. . HYPERTENSION: Continued home hydrochlorothiazide. Medications on Admission: cholecalciferol 400 U daily budesonide-formoterol 160-4.5 mcg 2 inh BID hydrochlorothiazide 25 mg daily levoxl 50 mcg /100 mcg daily alternating tiotropium bromide 18 mcg Inh daily levalbuterol 45 mcg/actuation inhalation HFA 2 puff QID 1 multivitamin daily Discharge Medications: 1. Home Nebulizer Dx: COPD 2. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation q3-6h. Disp:720 ML(s) Refills:2 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 10 mg Tablet Sig: ___ Tablets PO once a day for 13 days: take 40 mg PO daily for 3 days, then 20 mg PO daily for 5 days, then 10 mg PO daily for 5 days. Disp:27 Tablet(s) Refills:0 7. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day: start once other prednisone prescription finishes on ___. Disp:30 Tablet(s) Refills:0 8. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. budesonide-formoterol 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 12. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6 hours) as needed for congestion for 4 days. Disp:160 ML(s) Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute exacerbation of chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure caring for you at ___. You were admitted to the hospital for a COPD exacerbation. You had a chest x-ray that was reviewed by your pulmonologist, who did not think that it showed any pneumonia. You were started on prednisone, which you will need to take as prescribed. We tried giving you a medication called theophylline, but it may have caused your heart rate to increase, so we stopped it. Medication changes: start prednisone 40 mg by mouth daily for three days, then 20 mg by mouth daily for five days, then 10 mg by mouth daily for five days, then 5 mg by mouth daily until seen by Dr. ___ 0.63 mg / 3 mL nebulizer inhaled every ___ hours daily, or use your ___ inhaler as you were before being admitted to the hospital, but do not take double doses start guaifenisen ___ mL by mouth every six hours as needed for cough Followup Instructions: ___
19835663-DS-5	19,835,663	22,532,901	DS	5	2151-11-23 00:00:00	2151-11-23 18:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Thoracic cord compression Major Surgical or Invasive Procedure: ___ T9-T11 corpectomy through a costovertebral approach with T7-L1 posterior instrumented fusion, autograft History of Present Illness: Mr. ___ is a ___ who works in ___ with no PMHx, no known IVDU, who is being transferred from ___ after MRI revealed marked thoracic cord compression ___ vertebral abscess. Patient initially presented to ___ on ___ with complaints of ___ LBP with associated bilateral lower extremity radiculopathy; numbness/tingling/weakness. He denied any fevers/chills, bowel/bladder incontinence, had no trauma to the area. Lower extremity motor function was noted to be maintained. He endorsed occasional marijuana use but denied any IVDU. Utox only positive for marijuana. He was admitted with concomitant ___ that resolved with IVF administration and his back pain was treated conservatively with analgesics and cyclobenzaprine. Ultimately, however, an MRI on ___ revealed marked T11/T12 protrusion of swollen bone tissue with multiloculated rim-enhancing abscess into the spinal canal causing marked spinal stenosis and significant compression of the thoracic spinal cord. Additional bilateral paraspinal rim-enhancing abscesses are seen as well. Due to the possible need for surgical decompression and drainage, he was transferred to ___. Of note, he had not been started on any antibiotic treatment prior to transfer. - Vitals prior to transfer were: 97.5 \| 73 \| 117/72 \| 18, 100%ra - Labs were notable for: Cr 1.8 -> 1.0; Utox + for marijuana but otherwise negative; notably no leukocytosis or abnormal differential. - Studies were notable for: MRI findings as above. On arrival to the floor, patient endorses HPI as written above. He endorses current lower back pain as well as continued bilateral lower extremity radiculopathy. He ___ numbness/tingling sensation in bilateral anterior thighs and a sensation, when standing, that his legs are going to give out. He further endorses RLQ abdominal pain that began at the same time as his LBP. He denies any f/c, bowel/bladder incontinence. He continues to be able to ambulate independently. He denies any IVDU as well as h/o injections of any kind. He is a competitive ___ (pulls cars with his teeth), denies anabolic steroid use. His most recent travel was back to ___ ___ years ago. He ___ many tattoos, his most recent being ___ months ago which was done at a place he regularly goes to and states that are a reputable place which always use clean needles. He ___ had no recent infections, skin breaks. He does endorse intermittent night sweats for the last ___ weeks. Otherwise denies vision changes, HA, neck pain, cp, palpitations, SOB. Past Medical History: None Social History: ___ Family History: - No h/o neurological disease. - Mother died of breast cancer at age ___. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: 97.9 \| 130/86 \| 91 \| 18 98% Ra GENERAL: AOx3. NAD. Mild discomfort with movement. Pleasant and conversant. Many tattoos on upper body and b/l upper extremities. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: Symmetric, non-erythematous. Spinal and paraspinal tenderness primarily in lower thoracic/upper lumbar region. ABDOMEN: Normal bowels sounds, soft, non distended, mildly ttp in RLQ. +Psoas sign EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: CN2-12 intact. ___ strength in upper extremities b/l. Strength ___ in hip flexion/extension, leg flexion/extension, dorsi/plantarflexion. Antalgic gait, but able to ambulate independently. Sensation intact throughout. DISCHARGE PHYSICAL EXAM: ======================== ___ 0736 Temp: 98.1 PO BP: 140/84 R Sitting HR: 100 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: alert, NAD, laying down in his bed HEENT: anicteric sclerae, tongue laceration improving CV: S1 and S2 RRR, no MGR LUNGS: CTAB, no wheezes or crackles ABD: soft, nontender, nondistended, no hepatosplenomegaly EXT: no edema SKIN: warm, extensive tattoos on arms and chest. Petechiae on bilateral thighs and shins improving NEURO: alert, sensation intact, moves all four extremities. Motor ___ diffusely Pertinent Results: ADMISSION LABS: =============== ___ 05:10AM BLOOD WBC-9.6 RBC-5.01 Hgb-14.6 Hct-45.5 MCV-91 MCH-29.1 MCHC-32.1 RDW-13.6 RDWSD-45.1 Plt ___ ___ 05:10AM BLOOD Neuts-50.7 ___ Monos-11.6 Eos-3.4 Baso-0.7 Im ___ AbsNeut-4.85 AbsLymp-3.18 AbsMono-1.11* AbsEos-0.33 AbsBaso-0.07 ___ 05:10AM BLOOD ___ PTT-29.2 ___ ___ 05:10AM BLOOD Glucose-86 UreaN-18 Creat-1.1 Na-141 K-4.1 Cl-103 HCO3-24 AnGap-14 ___ 05:10AM BLOOD ALT-27 AST-17 LD(LDH)-130 CK(CPK)-61 AlkPhos-105 TotBili-<0.2 ___ 05:10AM BLOOD Albumin-4.4 Calcium-9.8 Phos-4.3 Mg-2.0 UricAcd-4.9 ___ 05:10AM BLOOD CRP-7.2* ___ 05:10AM BLOOD HIV Ab-NEG INTERVAL LABS: ============== ___ 05:30AM BLOOD ALT-50* AST-38 AlkPhos-78 TotBili-<0.2 ___ 06:01AM BLOOD ALT-113* AST-67* LD(LDH)-204 AlkPhos-89 TotBili-<0.2 ___ 05:55AM BLOOD ALT-149* AST-81* LD(___)-227 AlkPhos-90 TotBili-0.2 ___ 05:49AM BLOOD ALT-133* AST-60* LD(LDH)-292* AlkPhos-91 TotBili-<0.2 ___ 06:23AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 06:23AM BLOOD HCV Ab-NEG MICROBIOLOGY: ============= Mycobacterium tuberculosis Complex, PCR, Non-Respiratory ___ 12:39 SOURCE: VERTEBRAL ABSCESS MTB COMPLEX, PCR,NON RESP - DETECTED A REFERENCE RANGE: NOT DETECTED This test should not be used as a substitute for culture. It should be used as an adjunct to culture. The method used in this test is Real-Time PCR of the IS ___ locus of the M. tuberculosis complex. This test was developed and its analytical performance characteristics have been determined by ___ Infectious Disease. It ___ not been cleared or approved by the ___.S. Food and Drug Administration. This assay ___ been validated pursuant to the ___ regulations and is used for clinical purposes. This test should not be used for diagnosis without confirmation by other medically established means __________________________________ QUANTIFERON(R)-TB GOLD PLUS, 4T, INCUBATED RESULT: POSITIVE A REFERENCE: NEGATIVE __________________________________ ___ 5:10 am BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________ ___ 12:39 pm SWAB EPIDURAL ABSCESS. R/O TB. TB PCR CAN NOT BE RUNNED ON SWAB. NOTIFIED ___ 13:50 ___. . GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. __________________________________________ ___ 12:39 pm TISSUE EPIDURAL ABSCESS. R/O TB. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ____________________________________________ ___ 7:45 pm SPUTUM Source: Induced RECEIVED ON ___. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): MTB Direct Amplification (Final ___: M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. . NAAT results will be followed by confirmatory testing with conventional culture and DST methods. This TB NAAT method ___ not been approved by FDA for clinical diagnostic purposes. However, this laboratory ___ established assay performance by in-house validation in accordance with ___ standards. . Test done at ___ Mycobacteriology ___.. . IMAGING AND REPORTS: ==================== MR ___ W/O CONTRAST ___ 1. T9-T11 osteomyelitis and discitis with destruction of vertebral bodies resulting in focal kyphotic angulation which in combination with a posterior epidural abscess at this level results in severe spinal canal stenosis and compression of the spinal cord but without cord signal abnormality. 2. Inflammatory changes surrounding the T10 and T11 vertebral bodies with perispinal and intramuscular abscesses as described above. 3. No evidence of cord compression, severe spinal canal stenosis or significant neural foraminal narrowing along the cervical or lumbar levels. CT T-SPINE W/O CONTRAST ___ IMPRESSION: 1. 12 rib-bearing vertebrae and 5 non-rib-bearing vertebrae with partial sacralization of L5. 2. Discitis/osteomyelitis involving T9 through T11 are again demonstrated. Complete fragmentation and destruction of T10 vertebral body and bilateral pedicles. Severe loss of height of T9 and T11. Kyphotic angulation at T9-T10 with multiple bone fragments dorsal to T9-T11. Associated epidural phlegmon/abscess and spinal canal narrowing are better assessed on the preceding MRI. 3. Well corticated lucency extending into the left T9 posterior elements and to the left T8-T9 facet joint, likely sequela of the osteomyelitis. Well corticated irregularity of the right T10-T11 facet joint, unclear whether secondary to infection or secondary degenerative change. 4. Left T8-T9 and bilateral T9-T10 facet joints are perched. 5. Bilateral paraspinal collection at T9 through T11. A left paraspinal collection demonstrates peripheral calcifications which may be secondary to underlying sequestrum or underlying calcified lymph node, given the presence of other calcified lymph nodes in the visualized abdomen. 6. Multiple calcified mesenteric and retroperitoneal lymph nodes in the partially imaged abdomen, suggesting granulomatous disease. COMMENT: TB should be considered given involvement of 3 vertebral levels and calcified intra-abdominal lymph nodes. ADDENDUM There is a 15 x 14 mm spiculated nodule with multiple central calcifications in the apical left upper lobe, suggesting prior granulomatous disease, image 2:19. Adjacent nonspecific 4 mm nodule on image ___ also be related to prior granulomatous disease. Additional scattered punctate calcified pulmonary granulomas are noted in the right lower lobe on images 2:62, 2:75. There is moderate dependent atelectasis in the visualized portion of the lungs. CHEST (PORTABLE AP) ___ There is no focal consolidation, pleural effusion or pneumothorax. Subsegmental atelectasis is noted in the left lower lobe. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities are identified. There is partially visualized posterior spinal fusion hardware in the lower thoracic and upper lumbar spine. An expandable vertebral body cage is seen in the lower thoracic spine. IMPRESSION: No pneumonia or acute cardiopulmonary process. CT ABD & PELVIS WITH CONTRAST ___ 1. Discitis osteomyelitis and fractures involving the T10 and T11 vertebral bodies with new posterior fixation. 2. Multiple rim enhancing collections are seen in the paraspinal musculature likely represent abscesses. 3. 1.4 cm hypodense lesion in the right hepatic lobe is incompletely characterized in a single phase CT and visualization is partially limited by posterior spinal fusion hardware artifact. While in the context of this patient this could represent an abscess, hemangioma is also possible. 4. Multiple calcified lymph nodes and lymphadenopathy in the mesentery and retroperitoneum is likely related to granulomatous disease. 5. Please refer to separately reported chest CT for intrathoracic findings. 6. Possible thickening of the left adrenal gland. CT CHEST W/CONTRAST ___ 1. Discitis-osteomyelitis centered at T10-T11 vertebral bodies with fractures of both vertebrae, and surrounding soft tissue thickening is now fixated via T8 through L1 posterior fusion hardware as well as status post T10-T11 laminectomy. 2. Possible enhancement of the posterior aspect of the thecal sac is not well characterized on this study. Partially seen epidural catheter. 3. Multiple rim enhancing collections in the posterior mediastinum bilaterally are concerning for abscesses. 4. 1.4 cm spiculated calcified nodule in the left apex of the lung small calcified hilar lymph nodes are likely related to granulomatous disease. 5. Bibasilar atelectasis. 6. Please refer to separately reported abdominopelvic CT performed at the same time for subdiaphragmatic findings. LIVER OR GALLBLADDER US (SINGLE ORGAN) ___ 1. 1.5 cm right hepatic hemangioma corresponds to lesion seen on prior CT. 2. Re-demonstrated are multiple calcified lymph nodes in the peripancreatic and perihepatic space. 3. A tiny hypoechoic area in the gallbladder wall measuring up to 6 mm is nonspecific, but may represent focal adenomyomatosis. T-SPINE ___ Patient is status post corpectomy in the lower thoracic spine at approximately T9-T11 level with a vertebral body spacing device in-situ. Endplate destruction of these vertebrae is unchanged compared to the prior CT study. Overall alignment is unchanged. No fracture seen. No new areas of endplate destruction appreciated. IMPRESSION: Postoperative changes as described, no significant interval change when compared to the prior CT study. LIVER OR GALLBLADDER US (SINGLE ORGAN) ___ 1. Multiple echogenic hepatic lesions are compatible with hemangiomas. No sign of abscess is identified. 2. Multiple enlarged, heterogeneous periportal and peripancreatic lymph nodes are re-demonstrated. Brief Hospital Course: Mr. ___ is a ___ with no PMHx, transferred from ___ after MRI revealed marked thoracic cord compression ___ vertebral abscess/discitis/osteomyelitis s/p T9-11 corpectomy with T7-L1 fusion, started on RIPE therapy ___ for presumed spinal TB which was confirmed by PCR and positive QGold. ACUTE/ACTIVE ISSUES: ==================== # Spinal TB # T9-11 discitis and osteomyelitis # s/p T9-T11 corpectomy with T7-L1 fusion # Pain Patient with no known IVDU initially presented to OSH with 5 days of LBP and associated b/l ___ numbness/tingling/weakness. No fevers, bowel or bladder dysfunction. MRI imaging revealed significant thoracic cord compression iso epidural/paraspinal/intramuscular abscess, discitis, and spondylitis of unclear etiology. Also noted to have bilateral paraspinal rim-enhancing abscesses. He was transferred to ___ where he was started on empiric antibiotics and underwent T9-T11 corpectomy through with T7-L1 posterior instrumented fusion on ___. There was high suspicion for TB spondylodiscitis (Potts disease) given involvement of multiple vertebrae, calcified LNs and pulmonary nodule. He was started on Rifampin, Isoniazid, Pyrazinamide, Ethambutol, Pyridoxine on ___. Antibiotics were stopped on ___. MTB PCR from vertebral abscess was positive confirming TB. Pain was controlled with lidocaine patch and oxycodone. Ortho-spine recommended avoiding NSAIDS until f/u. Acetaminophen was discontinued per ID recommendation due to c/f hepatotoxicity with RIPE. He will need to continue RIPE regimen for two months and will continue on isoniazide and rifampin after. Tentative course of ___ months. He should also get a f/u CT chest in 6 months to reassess rim enhancing lesions. #Transaminitis ___ rashes Patient's liver enzymes started increasing after initiating RIPE therapy. Likely due to drug effect. Isoniazid ___ been known to cause mild transaminitis. RIPE was briefly held for increasing transaminases, but levels decreased before his next dose, so RIPE was resumed. Will need weekly monitoring of LFTs and CBC as an outpatient. Patient noted to have petechiae on bilateral LEs noted after initiation of RIPE, also thought to be a drug effect. Rash was stable. # Mediastinal abscess Patient had a CT torso that showed rim enhancing lesion c/f posterior mediastinal abscess. ID recommended no drainage and with follow-up imaging in 6 months. # Folliculitis Noted to have pustular lesions and erythema on lower forehead, thought ___ prolonged OR time prone. Improved with topical clindamycin x7d. # Right sided hepatic hemangioma. Noted on CT and confirmed on RUQUS, currently sized at 1.5 cm. Asymptomatic. CHRONIC/STABLE ISSUES: ====================== #Nicotine Dependence Provided Nicoderm patch. TRANSITIONAL ISSUES: ==================== [] Weekly monitoring of LFTs and CBC as an outpatient, send results to PCP and ___ ID follow up scheduled with PCP and if LFTs are concerning, ID will coordinate sooner follow up. [] Please continue to monitor petechial rash on patient's bilateral legs. [] Please ensure the patient ___ monthly vision testing with ophthalmology. [] Please ensure the patient follows closely with infectious disease. [] Please ensure the patient follows up with ortho-spine. [] Should get f/u CT chest in 6 months to reassess rim enhancing lesions. [] Possible thickening of left adrenal gland noted on CT. [] Should not take Tylenol while on RIPE. [] avoid NSAIDs until ortho-spine f/u. This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY RX bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 2. Cyclobenzaprine 5 mg PO BID:PRN back pain RX cyclobenzaprine 5 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 3. Ethambutol HCl 1600 mg PO DAILY RX ethambutol 400 mg 4 tablet(s) by mouth once a day Disp #120 Tablet Refills:0 4. Isoniazid ___ mg PO/NG DAILY RX isoniazid ___ mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Lidocaine 5% Patch 1 PTCH TD QAM RX lidocaine 5 % QAM Disp #30 Patch Refills:0 6. Lidocaine Viscous 2% 15 mL PO TID:PRN tongue lesion RX lidocaine HCl [Lidocaine Viscous] 2 % three times a day Disp #200 Milliliter Milliliter Refills:0 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Duration: 7 Days RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #28 Tablet Refills:0 8. Polyethylene Glycol 17 g PO BID RX polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth twice a day Disp #238 Gram Gram Refills:0 9. Pyrazinamide ___ mg PO DAILY RX pyrazinamide 500 mg 4 tablet(s) by mouth once a day Disp #120 Tablet Refills:0 10. Pyridoxine 50 mg PO DAILY RX pyridoxine (vitamin B6) 50 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 11. RifAMPin 600 mg PO DAILY RX rifampin 300 mg 2 capsule(s) by mouth once a day Disp #60 Capsule Refills:0 12. Senna 17.2 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 13.Outpatient Lab Work Check before ___: Hgb, Hct, WBC, Platelets, Differential, ALT, AST, AlkPhos, Total Bili, LDH. ICD-10: A18.01 Tuberculosis of spine. Fax results to: Dr. ___, Dr. ___, ___-- Attn: ___ and ___ ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Spinal tuberculosis s/p T9-T11 corpectomy with T7-L1 fusion Transaminitis Drug rash Mediastinal abscess Folliculitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for an infection in your spine. What was done for me while I was in the hospital? - You were found to have a tuberculosis infection involving your spine. - You had a back surgery to repair your spine and clean out the infection. - You were started on treatment for tuberculosis. You will need to continue this treatment for ___ months. Please continue to follow-up with your infectious disease doctors. - You were noted to have a mild rash on your legs which improved. We think this is a side effect of one of your medications being used to treat your infection. What should I do when I leave the hospital? - Do not take acetaminophen (Tylenol, Excedrin) while you are on treatment for tuberculosis. Please discuss this with your infectious disease doctors. - Do not take ibuprofen (Advil) or naproxen (Aleve) before you follow-up with your spine doctor. - Avoid alcohol while on treatment for tuberculosis. - Monitor your rash and call your doctor if it gets worse. - Continue taking your medications as prescribed - Keep all of your follow-up appointments. Sincerely, Your ___ Care Team Followup Instructions: ___
19835796-DS-12	19,835,796	28,641,985	DS	12	2169-06-06 00:00:00	2169-06-06 20:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Major Surgical or Invasive Procedure: none attach Pertinent Results: ADMISSION LABS: ============== ___ 06:10PM BLOOD WBC-22.7* RBC-5.04 Hgb-14.1 Hct-44.0 MCV-87 MCH-28.0 MCHC-32.0 RDW-15.6* RDWSD-49.5* Plt ___ ___ 06:10PM BLOOD Neuts-83.0* Lymphs-5.2* Monos-10.7 Eos-0.0* Baso-0.2 Im ___ AbsNeut-18.85* AbsLymp-1.18* AbsMono-2.42* AbsEos-0.01* AbsBaso-0.04 ___ 06:10PM BLOOD Glucose-79 UreaN-17 Creat-1.1 Na-144 K-4.4 Cl-99 HCO3-31 AnGap-14 ___ 06:10PM BLOOD cTropnT-0.02* ___ 08:59PM BLOOD cTropnT-0.01 ___ 07:08AM BLOOD %HbA1c-5.7 eAG-117 ___ 11:02PM BLOOD Cholest-136 ___ 11:02PM BLOOD Triglyc-50 HDL-60 CHOL/HD-2.3 LDLcalc-66 ___ 11:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 04:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG DISCHARGE LABS: ============== ___ 07:00AM BLOOD WBC-13.1* RBC-5.22 Hgb-14.6 Hct-44.3 MCV-85 MCH-28.0 MCHC-33.0 RDW-15.5 RDWSD-47.7* Plt ___ IMAGING: ======= CXR ___: No definite focal consolidation. Brief Hospital Course: BRIEF HOSPITAL COURSE: ==================== Mr. ___ is a ___ gentleman w/ hx of bipolar disorder, PTSD, & polysubstance use disorder who initially presented after an overdose after having taken crack cocaine, heroin, and clonidine. He received one dose of naloxone and bag valve mask respirations in the field with good response in his mental status. Subsequently required two doses of naloxone here in ED. He was found to have mildly elevated troponin to 0.02, which down-trended to 0.01. ECG was difficult to interpret given LVH, but had low suspicion for ischemia as he remained CP free throughout. Suspect that he may have had transient vasospasm from recent cocaine use. Social work was consulted, and placed him on a waitlist for an intensive outpatient addiction treatment program at ___. TRANSITIONAL ISSUES ==================== FOR PCP: [] Recommend referral to addiction psychiatry for ongoing treatment of patient's substance use disorder. [] On review of PMP, patient has been prescribed suboxone by Dr. ___). We did not prescribe any psychiatric medications here, as pt insisted on leaving before addiction psychiatry could evaluate him (and he was deemed to have capacity to leave) [] Patient was placed on waitlist for intensive outpatient addiction treatment program at ___. [] Consider stress test if pt c/o chest pain. MEDICATION CHANGES: - NEW: aspirin 81 mg daily + atorvastatin 40 mg daily # CODE STATUS: Full (presumed) # CONTACT: ___, mother, ___ ACTIVE ISSUES: =============== # Overdose # Polysubstance use disorder: Patient presented after an overdose on cocaine, heroin, and clonidine. He required treatment with Narcan and bag valve mask respirations with recovery of mental status. Patient has a longstanding psychiatric history, and had no acute safety concerns this admission. Patient denied suicidal ideation. He had no evidence of withdrawal. Social work was consulted, who placed patient on a waitlist for an intensive outpatient addiction treatment program at ___. We did not prescribe any psychiatric medications here, as pt insisted on leaving before addiction psychiatry could evaluate him (and he was deemed to have capacity to leave) # Elevated troponin Patient's troponins were mildly elevated (0.02>0.01) with no chest pain, no shortness of breath. EKG with nonspecific T wave changes. Elevated troponins occurred in the setting of cocaine use, and therefore likely due to vasospasm. AIC 5.7%, Cholest 136, LDL 66, HDL 60, ___ 50. Patient was started on aspirin 81 mg daily and atorvastatin 80 mg QHS. Beta blocker contra-indicated iso recent cocaine use. # Neutrophilic Leukocytosis Patient was noted to have WBC 22.7 on admission, which downtrended to 13.1. Suspect reactive iso overdose. Afebrile & no localizing s/s to point to infection. Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: ======== opioid, benzodiazepine, and cocaine overdose SECONDARY: ========== NSTEMI poly substance use disorder bipolar disorder post traumatic stress disorder leukocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you overdosed WHAT HAPPENED IN THE HOSPITAL? ============================== - We gave you naloxone to reverse the overdose - We did tests on your blood which showed that your heart was mildly injured, most likely because of your recent cocaine use - A social worker met with you, and was able to put you on a waitlist for an outpatient addiction program at the ___ ___ - You were started on two new medications, called aspirin and atorvastatin, to help protect your heart WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
19836124-DS-20	19,836,124	23,996,281	DS	20	2145-04-10 00:00:00	2145-04-13 22:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cyclobenzaprine / Metformin / bupropion HCl / Augmentin Attending: ___. Chief Complaint: hip fracture Major Surgical or Invasive Procedure: PROCEDURE: 1. Open biopsy with intraoperative frozen. 2. Proximal femoral replacement. Name: ___ ___ No: ___ Service: Date: ___ Date of Birth: ___ Sex: F Surgeon: ___, ___ ASSISTANTS: ___, MD PREOPERATIVE DIAGNOSIS: Pathologic subtrochanteric fracture of the left hip. POSTOPERATIVE DIAGNOSES: Pathologic subtrochanteric fracture of the left hip. PROCEDURE: 1. Open biopsy with intraoperative frozen. 2. Proximal femoral replacement. INDICATIONS FOR PROCEDURE: The patient is a ___ female patient with history of diabetes mellitus type 2, sickle cell trait, and history of left-sided renal cell carcinoma treated with left nephrectomy. The patient sustained a mechanical fall without any loss of consciousness with subsequent inability to ambulate and move. She was initially seen at ___, and then she was transferred to ___ for further care. She was evaluated recently by Dr. ___ on ___, for left hip pain in the Urgent Well Clinic and was discharged home with a walker with a pending MRI that was not done. The patient presented with a fracture, and I saw her for open biopsy and treatment of her injury. Informed consent was obtained in the inpatient setting. Discussed risks and benefits including intraoperative bleeding, neurovascular damage, change in histological diagnosis, need for further surgery, and limb discrepancy, as well as rotational deformities. DETAILS OF PROCEDURE: The patient was taken to the operating room and placed in the supine position on ___ table. She was induced under general anesthesia in the standard manner, and her airway was managed with an endotracheal tube. Subsequently, the patient was placed in the lateral position. The patient had compression boots during induction and in the right lower extremity during the surgery. The patient was positioned then in the lateral decubitus with assistance of a beanbag. All the bony prominences were adequately padded, and axillary roll was put in place. The patient was prepped and draped in the usual manner with ChloraPrep, and a timeout was performed to confirm the patient's identity, laterality, and procedure to be performed. The patient received preoperative antibiotics Ancef 2 g. Longitudinal incision following the lateral approach to the thigh and posterolateral to the hip was performed with a 10- size scalpel. Subsequent to that, the subcutaneous tissues were dissected with electrocautery down to fascia. The fascia was dissected longitudinally. Once the fascia was exposed, the gluteus medius was excised from the proximal femur in continuity with the vastus lateralis. We developed anterior and posterior flap also removing the external rotators, including the piriformis which was tagged with a #2 Ethibond stitch. All the portions of the psoas iliacus muscle and the gluteus minimus were also removed. The capsule was identified and was T'd in a reversed fashion. The horizontal tip of the T was down to acetabulum. The capsule was repaired with multiple 2 Ethibond stitches for subsequent repair. After the proximal fragment was completely freed, it was resected after removing the ligamentum teres. After this, we removed all other parts of remaining bone. We took some samples that we sent for frozen, and these confirmed to be a metastatic epithelioid carcinoma. After this, we identified the distal portion of the femur and then dissected further down the vastus lateralis from the fascia down to the linea aspera. Once we exposed a good portion of the bone, we resected an additional 3 cm and then we proceeded to ream with rigid reamers up to size 15 for cemented stem size 13. The femoral head measured size 48, and we used the trials using a standard body with a 30 mm insert and a standard stem 13 x ___. With these, we obtained adequate length and adequate stability of the hip. This was tested in knee flexion, internal and external rotation, rotational positioning, and length of extremity. Subsequent to this, we cleaned the femur, used a cement restrictor, and cleaned it with pulse lavage. We mixed 2 bags of cement without antibiotics, and after using the facing reamer, we inserted the stem with the whole body of the prosthesis assembled. The prosthesis was inserted without any difficulty after cementation. We confirmed adequate position and anteversion. Subsequently, after trialing again, we used a zero head 28 bipolar 48 mm. Subsequent to this, we obtained hemostasis, and subsequently we closed by planes, first the capsule and the attachments of the gluteus medius and vastus lateralis to the external rotators and posterior structures of the proximal hip. Subsequently, we closed with #1 Vicryl at the fascia and then subcutaneous tissues in a deep layer also with 0 Vicryl and superficial with ___ Vicryl. Skin was closed with staples. A sterile dressing with Xeroform, 4 x 4's, ABDs, and Tegaderms was applied. There were no complications during the case. No drains were left in place, as the surgical field was very dry. ESTIMATED BLOOD LOSS: 700 cc. INTRAVENOUS FLUIDS: 2 units of blood and 1500 cc of crystalloid. URINARY OUTPUT: 300 cc. COMPLICATIONS: There were no complications during the case. IMPLANTS: A ___ proximal femoral replacement GMRS with stem 13 x ___, interbody 30 mm, standard body head 28 bipolar x 48. Intraoperative x-rays demonstrated adequate placement of the stem. The patient was extubated without any difficulty and subsequently transferred to recovery. The patient is going to be weightbearing as tolerated postoperative day 1, preoperative antibiotics for 24 hours, DVT prophylaxis with 40 mg of Lovenox given her renal function and only working kidney. History of Present Illness: Ms. ___ is a ___ with history of DM type II, L-sided RCC s/p L nephrectomy, asthma, OSA, dCHF and rheumatoid arthritis with L-hip fracture s/p proximal femur replacement today with estimated blood loss of 1L with hypotension. Patient presented to ___ after falling backward onto her left hip with resultant left proximal femur fracture and was subsequently transferred to ___ for further care. She is now status post proximal left femur replacement today with estimated blood loss of 1L in the OR. She is status post 2 packs of pRBC and approximlatey 3L of NS between the OR and the PACU and continues to be tachycardic to the 110s and systolic pressures flucating between the ___ and is transfered to the FICU for further management. In the OR her pressures were between ___ to 110s/60s. Her baseline pressures seems to be 120-140s/40-60s though that seems to be her pressures while her antihypertensives were ___ yesterday and today she had most of her antihypertensives this morning including her Carvediolol, HCTZ and Valsartan. On arrival to the FICU she is awake and answering questions easily and only complains of pain in the left hip, especially when people are moving her. Past Medical History: Diastolic congestive heart failure/shortness of breath. Hypertension. Dyslipidemia. Valvular heart disease (1+MR). Asthma DM II Carpal Tunnel Syndrome Cataracts GERD OSA OSTEOARTHRITIS PPD POSITIVE Left RCC s/p nephroectomy Rheumatoid Arthritis H/O Temporal Arteritis PSH: L nephrectomy Cataract Surgery Social History: ___ Family History: Mother - emphysema secondary to tobacco use GM - breast cancer at age ___ No other cancers or MI in the family. Physical Exam: ================== ADMISSION EXAM ================== Vitals: 98 ___, 23->13 99% on 3L NC GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Decreased breath sounds at the right base, otherwise clear CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no edema. left hip bandaged and c/d/i SKIN: no ecchymosis or rashes NEURO: A&Ox3. Moving upper extremities and right lower extremity easily. ================== DISCHARGE EXAM ================== Vitals: T: 97.9 BP: 143/66 P: 82 R: 18 O2: 99% CPAP General: Alert, oriented x3, no acute distress. Able to do days of the week backwards with prompting Lungs: Bilateral expiratory wheezes in bilat lung fields. Crackles noted at lower lung fields CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: incision L hip c/d/i, appropriately tender Neuro: grossly intact Pertinent Results: ================ ADMISSION LABS ================ ___ 01:28PM BLOOD WBC-11.8* RBC-3.94 Hgb-10.6* Hct-34.6 MCV-88 MCH-26.9 MCHC-30.6* RDW-16.0* RDWSD-49.5* Plt ___ ___ 12:04AM BLOOD ___ PTT-20.4* ___ ___ 12:04AM BLOOD Glucose-272* UreaN-24* Creat-1.1 Na-136 K-3.9 Cl-95* HCO3-29 AnGap-16 ___ 01:28PM BLOOD CRP-44.4* ================ DISCHARGE LABS ================ ___ 05:32AM BLOOD WBC-14.8* RBC-3.07* Hgb-8.6* Hct-25.9* MCV-84 MCH-28.0 MCHC-33.2 RDW-16.5* RDWSD-48.7* Plt ___ ___ 05:32AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-139 K-3.9 Cl-103 HCO3-29 AnGap-11 ___ 05:32AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8 ================ PERTINENT LABS ================ ___ 01:05PM BLOOD PEP-NO SPECIFI FreeKap-30.5* FreeLam-31.9* Fr K/L-0.96 IgG-1119 IgA-397 IgM-35* ___ 09:20AM BLOOD 25VitD-28* ___ 05:05AM BLOOD VitB12-847 ___ 03:53AM BLOOD Hapto-326* ================ IMAGING ================ ___ CT PELVIS ORTHO: - Comminuted displaced subtrochanteric fracture of the left proximal femur. -Suggestion of underlying pathologic lytic lesion at the intertrochanteric region of the proximal left femur. -Moderate degenerative changes of the hips bilaterally. Mild degenerative changes the SI joint and pubic symphysis and lower lumbar spine. - Focal soft tissue changes in anterior abdominal wall on the right. ___ BONE SCAN 1.No evidence of osseous metastatic disease. 2.Increased uptake in the proximal left femur is consistent with history of recent fracture. ___ CHEST X-RAY As compared to ___ radiograph, pulmonary vascular congestion and mild edema are new. Patchy right basilar opacity is also new and may reflect focal atelectasis, aspiration, and less likely a focus of early pneumonia. ___ ___ No evidence of deep venous thrombosis in the bilateral lower extremity veins. ================ MICROBIOLOGY ================ Urine Cx x2 - no growth Blood Cx ___ - no growth ================ PATHOLOGY ================ L Femur Pathology: Sections reveal a small focus of epithelioid tumor cells with prominent clear cell features. By immunohistochemistry, these cells are positive for PAX-8 and CA-XI, and are negative for cytokeratins 7 and 20. The findings are consistent with metastatic renal cell carcinoma, clear cell type. Brief Hospital Course: The patient is a ___ female patient with history of diabetes mellitus type 2, sickle cell trait, and history of left-sided renal cell carcinoma treated with left nephrectomy. The patient sustained a mechanical fall without any loss of consciousness with subsequent inability to ambulate and move. She was found to have a L hip fracture now s/p hip replacement on ___. # Left hip fracture: s/p fall and now L hip replacement on ___. Imaging was concerning for a possible pathologic fracture. Pathology from OR was positive for renal cell carcinoma. Patient was followed by orthopedics and will see them as an outpatient. - Pain control with oxycodone ___ Q4H prn, lidocaine patches, standing acetaminophen. - PPx enoxaparin x 14 days post-op (last day is ___, she should have ortho f/u by this time) - Holding weekly methotrexate per ortho. This will be addressed by ortho at follow up - Staples to come out at appointment with ortho (two weeks after surgery) # Metastatic renal cell carcinoma. Patient was followed by oncology here. A family meeting was ___ on day of discharge to discuss diagnosis an options moving forward. She is to follow up with ortho, oncology, and radiation oncology. # Urinary retention. This has previously been a problem. Likely in the setting of having a foley placed. Patient required intermittent straight cath and bladder scanning. Will need to continue at rehap. # Constipation. Continue bowel regimen (senna and docusate) especially while on oxycodone for pain. # Altered mental status. Now resolved. Possibly related to better pain control. Continue pain medication as above for hip pain. # Fall: Likely mechanical fall secondary to poor balance/mis-step. No lightheadedness, dizziness, chest pain, palpitations, or LOC that would be suggestive of other causes, such as B12 deficiency, arrythmias, or orthostasis. B12 normal. # Leukocytosis: Likely stress response. Slowly downtrending. Pt overall feels well and no other SIRS criteria met. ___ now d/c'd. # Hypotension. Resolved. Suspect hypovolemic hypotension exacerbated by ___ meds including oxycodone as well as administration of home antihypertensives. Unlikely infectious given rapid resolution with IVF but without antibiotics. - Will need to restart antihypertensives (starting with valsartan) as an outpatient with close BP monitoring. # Anemia: Likely ___ bleeding. s/p 3U PRBCs (last on ___. Stabilized. # dCHF and HTN. EF>55% on ECHO of ___. Appears euvolemic. - Restart home valsartan and home carvedilol as outpatient. ___ in house in setting of hypovolemia, normal pressures/HR. # Asthma/COPD. Restarted home meds on discharge. # DM II. Restart home exenatide and levemir insulin on discharge. Her home sliding scale is unknown but she was requiring very little sliding scale coverage here. Her BGs should be monitored BID on discharge. # RA. Holding home methotrexate per ortho. # HLD. Reduceed Simvastatin to 40mg PO QPM # OSA. CPAP at night ======================= TRANSITIONAL ISSUES ======================= - Follow up appointments could not be made prior to discharge. Please ensure that these are made as detailed. She should she orthopedic surgery ___ or ___. - PCP to follow up if urinary retention is still an issue (required intermittent straight cath in hospital, likely ___ Foley placement) - PCP should schedule patient to have outpatient CT of chest/abd/pelvis and MRI of the head for cancer staging - Orthopedics to determine when methotrexate can be restarted - BP and dCHF meds can be restarted as outpatient, per PCP or rehab MD. ___ in house for hypotension. - Staples to be removed at ortho f/u appointment - Unclear home sliding scale insulin, monitor blood sugar BID and continue home levemir Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. Hydrochlorothiazide 25 mg PO DAILY 4. nortriptyline 10 mg oral qhs:prn pain 5. Simvastatin 80 mg PO QPM 6. Valsartan 320 mg PO DAILY 7. OxycoDONE (Immediate Release) 10 mg PO TID 8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 9. Methotrexate 15 mg PO 1X/WEEK (MO) 10. TraMADOL (Ultram) 50 mg PO TID:PRN pain 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN cough, wheeze 12. ammonium lactate 12 % topical BID 13. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 14. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY 16. FoLIC Acid 1 mg PO DAILY 17. Ipratropium-Albuterol Inhalation Spray 1 INH IH BID 18. Levemir 32 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 19. Acetaminophen 500 mg PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain 2. FoLIC Acid 1 mg PO DAILY 3. Nortriptyline 10 mg ORAL QHS:PRN pain 4. Simvastatin 80 mg PO QPM 5. Levemir 32 Units Bedtime 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #24 Tablet Refills:*0 7. Docusate Sodium 100 mg PO BID 8. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time Last day is ___ per orthopedics. This can be confirmed at ortho f/u appt. 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Senna 8.6 mg PO BID 11. ammonium lactate 12 % topical BID 12. Aspirin 81 mg PO DAILY 13. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID 14. Fluticasone Propionate NASAL 2 SPRY NU DAILY 15. Ipratropium-Albuterol Inhalation Spray 1 INH IH BID 16. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION Q6H:PRN cough, wheeze 17. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation INHALATION BID Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnosis - left hip fracture - metastatic renal cell carcinoma - acute blood loss anemia Secondary Diagnosis - compensated diastolic heart failure - type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure being a part of your care team at ___ ___. You were admitted to the hospital because of a hip fracture. We did surgery to fix your hip. You had to stay in the ICU for a few days because your blood pressure was low and you needed to receive some extra blood. After you were doing better you were able to come to the regular medicine floor, where you continued to do well. We are very sorry to tell you that the fracture is from the kidney cancer (renal cell carcinoma) that you had a long time ago. We were happy to meet with you and your family to discuss the next steps, which will involve seeing orthopedic surgery, radiation oncology, and medical oncology to discuss treatment options. Please see below for your follow-up appointment information and changes that we have made to your medications. You should not take your methotrexate until you speak with the orthopedic surgeons next week. They will tell you when to restart it. Again, we are very sorry to have to give you this news, and we wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
19836188-DS-2	19,836,188	20,532,464	DS	2	2136-03-26 00:00:00	2136-03-27 18:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left eye blurry vision Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: The patient is a ___ year old woman with PMH significant for previous MVA s/p multiple back surgeries and residual left leg numbness who presents with 1 day of left eye blurriness. The blurriness began all of a sudden while she was walking back into the school building after being outside during recess. She notes that for about 30 minutes prior to the blurry vision onset, she was unable to see while standing in the sun and required sunglasses or standing in the shade in order to see normally. Once the blurry vision began, it did not improve of worsen, but has remained constant since yesterday afternoon. She has been able to localize it to the left eye only, she feels the vision in the right eye is at baseline. There was no sensation of a curtain over the vision, loss of visual field, scintillations, bright spots or colors, or black spots. While she initially described this as "double vision," she is clear that she has never seen two overlapping images, that objects in her view appear blurred or smeared, sometimes with streaks, and this is more pronounced with objects in the distance or when looking at lights. She describes her vision as being like she is looking from underwater. She also notes a pressure-like sensation in the left side of her face and head that began several minutes after the blurry vision started. This has since progressed to an intermittent stabbing and squeezing pains in the back left side of her head. She notes a minor head injury 1.5 weeks ago in which she hit her head against the corner of a dresser and developed a large bruise on the head without skin breakage or LOC. Five hours after the onset of blurry vision, she presented to an outside ED where CTA head/neck was performed, but the study was limited. Given inability to rule out small aneurysm, she was transferred to BID for further evaluation. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies fevers, chest pain, palpitations, cough, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria or rash. Past Medical History: PMH/PSH: motor vehicle accident -s/p 3x abdominal surgeries -s/p 4x lower back surgeries -intermittent shooting sciatica Social History: ___ Family History: no known history of stroke, seizure, migraine headaches Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: 98.2 86 128/74 16 100% RA General: NAD, resting in bed HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes, sclerae anicteric Neck: Supple ___: RRR Pulmonary: CTAB Abdomen: Soft, NT, ND Extremities: Warm, no edema Skin: No rashes or lesions Neurologic Examination: - ___ stroke scale score: 0 - Mental Status - Awake, alert, oriented to person, place and time. Attention to examiner easily maintained. Recalls a coherent history. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No evidence of hemineglect. - Cranial Nerves - PERRL 3->2 brisk. VF full to finger counting. EOMI, no nystagmus. V1-V3 with 60% sensation in left V1-V3 distribution as compared to right (100%). No facial movement asymmetry. Hearing intact to finger rub bilaterally. No dysarthria. Palate elevation symmetric. Trapezius strength ___ bilaterally. Tongue midline. - Motor - Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 - Sensory - 60% diminished sensation on left anterior thigh, left lower leg to light touch and pinprick -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. - Coordination - No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. - Gait - not assessed DISCHARGE PHYSICAL EXAMINATION: Unchanged as above with the following additional finding: On visual acuity testing, patient was ___ in left eye and ___ in right eye. Pertinent Results: ___ 06:10AM 4.8 3.94 12.9 39.9 101* 32.7* 32.3 11.6 43.0 201 Import Result ___ 03:20AM 6.9 4.01 13.2 39.9 100* 32.9* 33.1 11.7 42.4 225 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps ___ AbsLymp AbsMono AbsEos AbsBaso ___ 03:20AM 56.8 32.0 9.2 1.2 0.4 0.4 3.90 2.20 0.63 0.08 0.03 Import Result BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___ ___ 06:10AM 201 Import Result ___ 03:20AM 225 Import Result ___ 03:20AM 11.4 25.6 1.1 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:10AM ___ 139 4.5 ___ Import Result ___ 03:20AM ___ 136 3.9 ___ Import Result ESTIMATED GFR (MDRD CALCULATION) estGFR ___ 03:20AM Using this Import Result ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili ___ 03:20AM 9 16 63 0.5 Import Result CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron ___ 06:10AM 8.8 2.8 2.0 Import Result ___ 03:20AM 3.7 8.8 3.0 2.1 Import Result DIABETES MONITORING %HbA1c eAG ___ 03:20AM 4.9 94 Import Result LIPID/CHOLESTEROL LDLmeas ___ 03:20AM 72 Import Result TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl ___ 03:20AM NEG NEG NEG NEG NEG NEG Import Result IMAGING: OSH CTA H and N: There is no intracranial hemorrhage. No focal abnormality is seen within the brain. The ventricles are normal in size and configuration. The paranasal and mastoid sinuses are clear. The bony calvarium appears intact. The neck, the common carotid, internal carotid, external carotid and vertebral arteries are patent with no dissection, aneurysm or stenosis. No enlarged lymph nodes are seen. Intracranially, there is prominent venous contamination, problematic at the cavernous portions of the internal carotid arteries with respect to potential small aneurysms in this location. No large aneurysm is seen. There is a prominent infundibulum of the right posterior communicating artery measuring 1.5 mm -1.8 in diameter tapering gradually to a normal caliber posterior communicating artery. Venous contamination at both cavernous sinuses limits evaluation for potential small cavernous portion aneurysms. The supraclinoid intracranial internal carotid arteries, middle and anterior cerebral arteries are unremarkable. No aneurysm seen elsewhere. The ertebrobasilar system is unremarkable within the brain. There is no intracranial stenosis or dissection. ___ Imaging: CTA H and N (___) : 1. No infarction, hemorrhage, edema, or mass lesion. 2. 2 mm focal outpouching arising from the cavernous portion of the left internal carotid artery, which may represent a small aneurysm. MRI Brain w/out contrast (___): No acute infarction and no evidence for other acute intracranial abnormalities. Brief Hospital Course: Ms. ___ was admitted for acute symptoms of blurry vision in the left eye with associated sharp head and neck pain. that started several minutes after visual symptoms began. Due to the abrupt onset, she was admitted for a stroke work up. Initially CTA imaging was done and it showed a small 2mm out-pouching of the ICA in the cavernous section of the brain. Neurosurgery was consulted for their expertise and it was not felt that intervention was needed given the location, appearance, and size of the outpouching. Also finding is incidental and is not linked to the patient's abrupt visual symptoms or head and neck pain. Likely, the patient was suffering from migraine with aura (complicated migraine) with neurologic symptoms (decrease in visual acuity) that will return to baseline once headache has improved. As migraine treatment, we recommended alternating Tylenol with ibuprofen and using anti emetics. We counseled the patient to consider changing her combined OCP to a progesterone-only pill or to discuss other contraception options with her outpatient provider. Ms. ___ did not have any significant neurologic deficits on the discharge day except for mild left eye blurry vision ___ visual acuity) that had improved since admission. In terms of the outpouching of the cavernous portion of the ICA, the patient will have repeat MRA imaging of her head and neck in one year to evaluate the size. Ms. ___ will follow up with the neurology stroke Attending as well in 3 months. Ms. ___ was discharged home. TRANSITIONS OF CARE ISSUES: 1. Follow-up with primary care provider ___ ___ weeks. 2. Follow-up with Dr. ___ Neurologist and call his office to schedule your appointment (___) 3. Please discuss whether you would like to consider changing your contraceptive pill to a progesterone-only pill or other options depending on your needs with your prescriber. 4. You will need to have an MRA brain and neck completed in ___ year to evaluate size of the outpouching (which is currently stable and at a small size) . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enpresse (levonorg-eth estrad triphasic) ___ (6)/75-40 (5)/125-30(10) oral DAILY 2. Ibuprofen 400-800 mg PO Q8H:PRN back pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ibuprofen 400-800 mg PO Q8H:PRN back pain Discharge Disposition: Home Discharge Diagnosis: Migraine with aura Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, you presented with blurry vision in your left eye. You were admitted to the hospital for evaluation of a possible stroke which was found to be negative on imaging. Incidentally, when imaging your vessels, a small possible 2mm outpouching was found on the internal carotid artery. This will be monitored and you will have repeat imaging in ___ year to ensure the size is stable. You will also follow-up with the stroke physician ___ ___ months. Likely, your symptoms can be explained by a migraine headache with neurologic features also called migraine with aura. Followup Instructions: ___
19836691-DS-20	19,836,691	21,097,398	DS	20	2134-06-06 00:00:00	2134-06-06 17:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Flomax Attending: ___. Chief Complaint: Headache, ptosis Major Surgical or Invasive Procedure: N/A History of Present Illness: Mr. ___ is a ___ year old male with history of COPD, CAD, PE and DVT who presents with a headache. He says that he developed an acute onset headache about two weeks ago. He says that he does not remember exactly what he was doing when it started. He says that he had some cough and congestion, and he was blowing his nose a lot. He denies any trauma or neck manipulation. He says that the headache was left sided, characterized by pressure. He says that it sometimes radiates to his teeth. He says that he has been nauseated but not had vomiting. He denies photophobia and phonophobia. He was seen by his PCP who prescribed amoxicillin out of concern for sinusitis. However, the headache continued unabated. About one week ago, his wife also noted that his left eyelid was droopy. He denies a positional component to the headache. He has had migraine headaches in the past but not had them for several years. He says that this headache does not feel like a migraine. Given the lack of improvement in the headache with antibiotics, he went to an OSH today, where a CT scan demonstrated findings concerning for a subarachnoid hemorrhage. He received vitamin K to reverse his Coumadin. Mr. ___ underwent cardiac catheterization in ___, and he had two stents placed in ___. He was also found to have small pulmonary emboli. He was initially on Plavix, but he then developed swelling of the foot and was found to have a DVT. He was switched to Coumadin, and he has been on Coumadin ever since. He does not think that he has ever been worked up for hypercoaguability. He states that he has occasional dizziness, but denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. General review of systems is notable for the viral symptoms that he had reported that have since resolved. Past Medical History: COPD CAD Asthma Migraine DVT/PE shoulder surgery Social History: ___ Family History: No known neurological disorders Physical Exam: PHYSICAL EXAM: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple Pulmonary: No increased WOB Cardiac: RRR Abdomen: soft, non-distended Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name days of the week backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. He made two paraphasic errors during the conversation. He was able to name both high frequency objects, had some difficulty with low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of neglect. -Cranial Nerves: II: Pupils equal and reactive to light, VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. Ptosis of the left eye. V: Facial sensation intact to light touch. VII: No facial droop, closes eyes tightly and unable to overcome VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with normal strength -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Delt Bic Tri WrE IO IP Quad Ham TA Gastroc L 5 ___ ___ 5 5 5 R 5 ___ ___ 5 5 5 -Sensory: No deficits to light touch -DTRs: Bi Tri ___ Pat Ach L 2 2 2 1 1 R 2 2 2 1 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. -Gait: Normal based gait Pertinent Results: ADMISSION LABS: ___ 11:02PM ___ ___ 09:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 09:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 09:45PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 09:45PM URINE MUCOUS-RARE ___ 04:45PM GLUCOSE-101* UREA N-16 CREAT-0.8 SODIUM-137 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16 ___ 04:45PM cTropnT-<0.01 ___ 04:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:45PM WBC-11.2* RBC-5.13 HGB-14.8 HCT-44.9 MCV-88 MCH-28.8 MCHC-33.0 RDW-13.3 RDWSD-42.9 ___ 04:45PM NEUTS-70.7 LYMPHS-15.7* MONOS-8.8 EOS-3.5 BASOS-0.8 IM ___ AbsNeut-7.91* AbsLymp-1.76 AbsMono-0.99* AbsEos-0.39 AbsBaso-0.09* ___ 04:45PM PLT COUNT-220 ___ 04:45PM ___ PTT-38.7* ___ ******** IMAGING: CT head ___ (OSH, ___ opinion here): IMPRESSION: 1. Small caliber of the visualized distal cervical left internal carotid artery with severe narrowing at the skullbase and of the horizontal petrous segment, and slight narrowing of the remaining petrous, cavernous, and supraclinoid segments. These findings are suspicious for dissection. 2. Increased number of small blood vessels in the region of the previously demonstrated left parietal subarachnoid hemorrhage. This may represent reactive hyperemia, but a developmental venous anomaly, or a subtle arteriovenous malformation or fistula, cannot be excluded on the basis of this exam. 3. No evidence for an intracranial aneurysm, allowing for absence of 3D volume rendered images on this exam from BID ___. 4. No evidence for dural venous sinus thrombosis. 5. Fluid, secretions, and mucosal thickening in the paranasal sinuses could be related to prolonged supine positioning or active sinus disease. Please correlate with symptoms. RECOMMENDATION(S): 1. Neck MRA with fat-suppressed axial T1 weighted images is recommended to assess for cervical left internal carotid artery dissection. Of note, this has already been performed at the time of final interpretation. 2. Conventional cerebral angiogram should be considered to exclude a subtle arteriovenous malformation or fistula in the region of the left parietal subarachnoid hemorrhage. MRI/MRA brain ___: IMPRESSION: 1. Small focus of left parietal subarachnoid hemorrhage is again demonstrated. No evidence for amyloid angiopathy is seen. No clear evidence for a cavernous malformation is demonstrated. Please refer to the preceding head CTA report for further observation and recommendations. 2. Dissection of the distal cervical left internal carotid artery at the skullbase and of the horizontal portion of the petrous segment with acute to subacute thrombus. Other portions of the left internal carotid artery are small in caliber compared to the right, which may reflect diminished flow secondary to the dissection, but chronic dissection of the more proximal cervical internal carotid artery cannot be excluded. 3. Otherwise, neck MRA is technically limited due to poor timing and motion artifact. 4. The motion limited MRA of the brain demonstrates no evidence for an aneurysm larger than 3 mm, concordant with the preceding head CTA. 5. No evidence of major dural venous sinus thrombosis. 6. Fluid and secretions in the paranasal sinuses may be secondary to prolonged supine positioning in the inpatient setting versus active sinusitis. Please correlate with symptoms. CXR 2v ___: FINDINGS: Lungs are relatively hyperinflated and there is relative lucency projecting over the right upper lung with changes in the underlying parenchyma raising the possibility of emphysema. There is also left apical scarring. There is no focal consolidation or edema. Moderate-sized hiatal hernia is noted. No acute osseous abnormalities. Right shoulder arthroplasty changes are noted. IMPRESSION: Hiatal hernia and findings suggestive of emphysema. No acute cardiopulmonary process. CT head noncontrast ___: IMPRESSION: 1. Stable small left parietal subarachnoid hemorrhage. No new hemorrhage. 2. Fluid and secretions in the paranasal sinuses may relate to prolonged supine positioning in the inpatient setting or active sinus disease. Please correlate with symptoms. Brief Hospital Course: Patient is a ___ year old male with history of CAD and PE/DVT on coumadin who presented with a headache and ptosis, subsequently found on CT with L ICA dissection and a small convexal left parietal SAH. He had no risk factors for dissection with exception of possible valsalva/sneezing. He has no physical exam findings to suggest a collagen vascular disorder. His imaging does not support fibromuscular dysplasia. His family history does not suggest a collagen vascular disorder. The CTA brain ___ opinion report mentioned concern regarding an "Increased number of small blood vessels in the region of the previously demonstrated left parietal subarachnoid hemorrhage. This may represent reactive hyperemia, but a developmental venous anomaly, or a subtle arteriovenous malformation or fistula, cannot be excluded on the basis of this exam. No evidence for an intracranial aneurysm, allowing for absence of 3D volume rendered images on this exam from ___ MRI brain/MRA brain showed no evidence of an AVM or amyloid angiopathy. Neurosurgery (Dr. ___ was consulted for possibility of performing angiography to rule out arteriovenous malformation, dural AV fistula, or aneurysm, but he thought that these were highly unlikely to be present and that the risks of the procedure outweighed the benefits. In the final analysis, the small left parietal SAH appeared likely spontaneous, in setting of anticoagulation. Dr. ___ discussed with his cardiologist who had been treating Mr. ___ with Coumadin for the DVT and PE. The cardiologist confirmed that the DVT and PE occurred more than one year ago. Given the risks and benefits, his cardiologist was in agreement with not resuming the Coumadin. His Coumadin was stopped and he was placed on aspirin 81mg. He was treated with SBP goal <160, and he was continued on his home lasix and lisinopril. His headache was controlled with fioricet and compazine and he was arranged for a follow up MRI in ___s follow up in Stroke clinic. Transitional issues: [ ] Coumadin was stopped and aspirin 81mg was started for cardiovascular prevention in setting of admission with subarachnoid hemorrhage. If felt that his risk of DVT/PE is high enough or he experiences recurrence, please consider consultation for placement of IVC filter. [ ] Please follow up repeat MRI head brain without contrast/ MRA brain without contrast/MRA neck w/wo contrast to assess for resolution of SAH and carotid dissection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Lisinopril 20 mg PO DAILY 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Pantoprazole 40 mg PO Q12H 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 8. Furosemide 20 mg PO DAILY 9. Warfarin 10 mg PO 4X/WEEK (___) 10. Warfarin 7.5 mg PO 3X/WEEK (___) 11. Albuterol Inhaler ___ PUFF IH Q4H:PRN as directed Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN as directed 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Furosemide 20 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Pantoprazole 40 mg PO Q12H 8. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:5 9. Multivitamins 1 TAB PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headaches RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s) by mouth every 6 hours as needed Disp #30 Tablet Refills:1 12. Prochlorperazine ___ mg PO Q6H:PRN Nausea or headache RX prochlorperazine maleate [Compazine] 5 mg ___ tablet(s) by mouth every 6 hours as needed Disp #30 Tablet Refills:0 13. Amitriptyline 25 mg PO QHS RX amitriptyline 25 mg 1 tablet(s) by mouth nightly Disp #30 Tablet Refills:3 Discharge Disposition: Home Discharge Diagnosis: Left parietal convexal subarachnoid hemorrhage Left internal carotid artery dissection Recent PE/DVT Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for headache and left eyelid droop. We found that you had a small area of hemorrhage in your brain, as well as a small tear in one of the blood vessels in your neck. We thought that the conclusion that these were not related and likely incidental, but both were probably contributing to your headache. To ensure that the hemorrhage and the vessel tear resolve, you will need a repeat brain and neck MRI in 3 months, for which you will be contacted to arrange. For treatment, we stopped your Coumadin due to the increased risk of further bleeding, and we started aspirin to treat the blood vessel tear. You should take aspirin 81mg indefinitely. You may continue to take analgesic medications for the headache, and try to wean off this when tolerable. Drink plenty of fluids. Your symptoms are expected to slowly improve over the next few weeks. If your headache significantly worsens OR you develop new neurologic symptoms (listed below in danger signs), please seek medical attention. It was a pleasure taking care of you. We wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
19836774-DS-5	19,836,774	25,820,905	DS	5	2161-07-19 00:00:00	2161-07-19 10:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R thigh pain Major Surgical or Invasive Procedure: ORIF R femur w/ anterograde Synthes 380 x 11 mm IMN History of Present Illness: Patient is a ___ yo M who was driving home from work on the highway tonight when he believes a car cut him off and he rear-ended it. He states he was going 65-70 mph, and he was alone in the car. Airbags went off, positive head strike, no LOC or HA. Noted severe pain in the right thigh and was unable to get out of his car when it stopped. He was brought to ___ from the scene hemodynamically stable and with a GCS of 15. In the trauma bay he complained of right thigh pain, left arm abrasions, and left chest wall tenderness. He was pan-scanned and cross-sectional imaging studies were negative. Xrays demonstrated an isolated right femur fracture and Ortho was consulted. Past Medical History: Meniscal tear in right knee s/p arthroscpy Meniscal tear in left knee managed conservatively Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM 98.0, 89, 145/76, 15, 100% RA AVSS, Resting, mild distress Nonlabored breathing Regular pulse Abdomen soft and nontender Mild left chest wall tenderness Pelvis stable to AP compression Left upper extremity: Abrasions over extensor surface of forearm Abrasions over ulnar aspect of left hand Two lacerations near left elbow sutured closed by ER resident Normal active pain-free ROM shoulders/elbows/wrists/hands No deformity or crepitus ___ strength biceps/triceps/WE/WF/DIO/EPL/FDP SILT median/radial/ulnar 2+ radial pulse, WWP Right upper extremity: Mild abrasions near right elbow Normal active pain-free ROM shoulders/elbows/wrists/hands No deformity or crepitus ___ strength biceps/triceps/WE/WF/DIO/EPL/FDP SILT median/radial/ulnar 2+ radial pulse, WWP Left lower extremity: Full pain-free ROM hip/knee/ankle foot Able to straight leg raise ___ ___ SILT DP/SP/T/S/S 2+ DP pulse, WWP Right lower extremity: Notable deformity of right femur Positioned in hip ER and knee flexion Visible skin intact throughout Positive ___ SILT DP/SP/T/S/S 2+ DP pulse, WWP DISCHARGE PHYSICAL EXAM Pertinent Results: ADMISSION LABS ___ 10:05PM BLOOD WBC-16.2* RBC-5.13 Hgb-15.8 Hct-45.0 MCV-88 MCH-30.9 MCHC-35.2* RDW-12.4 Plt ___ ___ 10:05PM BLOOD ___ PTT-24.1* ___ ___ 10:05PM BLOOD ___ 10:05PM BLOOD UreaN-17 Creat-1.00 BLOOD Glucose-98 Lactate-2.0 Na-141 K-4.9 Cl-106 calHCO3-26 ___ 10:05PM BLOOD Lipase-33 DISCHARGE LABS ___ 01:25PM BLOOD Hct-31.9* ___ 05:18AM BLOOD WBC-10.0 RBC-3.38* Hgb-10.4* Hct-29.6* MCV-88 MCH-30.7 MCHC-35.0 RDW-12.5 Plt ___ ___ 11:45AM BLOOD Glucose-134* UreaN-10 Creat-1.0 Na-137 K-3.6 Cl-100 HCO3-30 AnGap-11 ___ 11:45AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9 IMAGING: Right knee/ankle/foot Xrays: Suboptimal views. No evidence of fracture or malalignment. AP pelvis and right femur xrays: Comminuted segmental diaphyseal right femur fracture with significant shortening and angulation of the intervening fragment. CT Chest/Abdomen/Pelvis:No acute intra-thoracic or intra-abdominal pathology. CT head and C-spine: No acute intracranial injury. No fracture or malalignment of the C-spine. Brief Hospital Course: The patient was admitted to the Orthopaedic Trauma Service for repair of a right midshaft femur fracture. The patient was taken to the OR and underwent an uncomplicated open reduction/internal fixation with an anterograde Synthes 380 x 11mm IMN. The patient tolerated the procedure without complications and was transferred to the PACU in stable condition. Please see operative report for details. Post operatively pain was controlled with a PCA with a transition to PO pain meds once tolerating POs. The patient tolerated diet advancement without difficulty and made steady progress with ___. Weight bearing status: weight-bearing as tolerated right lower extremity. The patient received ___ antibiotics as well as lovenox for DVT prophylaxis. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 2 weeks post-operatively. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX oxycodone 5 mg ___ tablet(s) by mouth every four to six (___) hours Disp #100 Tablet Refills:0 2. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Doses RX enoxaparin 40 mg/0.4 mL inject into abdomen once a day Disp #14 Syringe Refills:0 3. Acetaminophen 650 mg PO Q6H standing dose 4. Docusate Sodium 100 mg PO BID 5. Senna 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: R midshaft femur fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ****WOUND CARE** - You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. No dressing is needed if wound continued to be non-draining. **WEIGHT-BEARING** - Weight-bearing as tolerated right lower extremity **MEDICATIONS** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink eight 8-oz glasses of water daily and take a stool softener (colace) to prevent this side effect. - Medication refills cannot be written after 12 noon on ___. **ANTICOAGULATION**** - Take Lovenox for DVT prophylaxis for 2 weeks post-operatively. Followup Instructions: ___
19836795-DS-17	19,836,795	25,062,453	DS	17	2141-05-22 00:00:00	2141-05-22 13:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___ Cardiac catheterization ___ Mitral valve replacement with a 27 mm ___ tissue valve. Coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and a saphenous vein graft to diagonal and posterior descending arteries. Endoscopic harvesting of the long saphenous vein. ___ left chest tube placement ___ tracheostomy ___ right pigtail placement ___ Bronchoscopy ___ percutaneous endoscopic gastrostomy ___ tunneled HD line History of Present Illness: Ms. ___ is a ___ year old woman with a history of chronic obstructive pulmonary disease. She presented to ___ for evaluation of shortness of breath. She was in her normal state of health until the night prior to admission, when she developed new onset shortness of breath. She stated that her symptoms came on fairly suddenly. She states she was not doing anything outside her normal activity when this SOB came on. She presented to the emergency department at ___, and she was noted to be cyanotic-appearing. She had a BNP of 18,000 and troponin of 0.43. She was placed on BiPAP with some improvement in her symptoms and oxygenation. They tried her off BiPAP for about an hour, but she reportedly failed. She received 40 IV Lasix there and duonebs. After failing bipap, was transferred to ___ for further evaluation and management. She underwent a cardiac work up which revealed a depressed ejection fraction of 30%. She had moderate to severe mitral regurgitation. A cardiac catheterization revealed significant multivessel disease. She was referred for cardiac surgical evaluation. Past Medical History: Chronic obstructive pulmonary disease Social History: ___ Family History: Father: deceased, died from stroke. ___ years ago, does not remember age at death. prior history MI, throat cancer Mother: deceased, died of dementia. Sisters/Brothers: no significant PMH Daughter: asthma, fibromyalgia Maternal aunt: lupus No family history of sudden cardiac death Physical Exam: ==================== ADMISSION EXAM ==================== VS: P ___ BP 134/61 R 28 Sat 100% on BiPAP ___ 30% GEN: Pleasant and cooperative, in mild discomfort with BiPAP machine in place, +accessory muscle use. HEENT: No conjunctival pallor or scleral icterus noted. NC/AT CV: RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops noted; heart sounds soft and difficult to appreciate ___ BiPAP machine LUNGS: Trace bibasilar crackles. End-expiratory wheezes noted diffusely in bilateral lung fields. ABD: Hypoactive bowel sounds. Abdomen soft, NTND EXT: WWP, 2+ pitting edema to shin b/l SKIN: no rashes or ecchymoses noted. waxy hyperkatotic lesions noted on skin of face, neck, and back diffusely. NEURO: Alert and oriented. CN ___ grossly intact. Moving all extremities and following commands appropriately. ==================== DISCHARGE EXAM ==================== General Appearance: Anxious, awake and interactive-trached HEENT: PERRL Cardiovascular: (Rhythm: Irregular), AFib Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchorous : scattered, Diminished: bilat), (Sternum: Stable ) Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present, PEG site-CDI Right Lower Extremity : (Edema: Absent), (Temperature: Warm), (Pulse - Dorsalis pedis: Diminished +1) Left Lower Extremity: (Edema: Absent), (Temperature: Warm) Skin: (Incision: Clean / Dry / Intact) Neurologic: Follows simple commands, (Responds to: Verbal stimuli), Moves all extremities, awake and interactive-follows simple commands-mouths words Pertinent Results: ===================== ADMISSION LABS ===================== ___ 02:55PM BLOOD WBC-15.3* RBC-4.20 Hgb-12.2 Hct-37.1 MCV-88 MCH-29.0 MCHC-32.9 RDW-13.7 RDWSD-44.3 Plt ___ ___ 02:55PM BLOOD Neuts-96.3* Lymphs-2.0* Monos-0.7* Eos-0.1* Baso-0.2 NRBC-0.1* Im ___ AbsNeut-14.73* AbsLymp-0.31* AbsMono-0.11* AbsEos-0.01* AbsBaso-0.03 ___ 02:55PM BLOOD ___ PTT-25.4 ___ ___ 02:55PM BLOOD Glucose-98 UreaN-25* Creat-1.2* Na-145 K-3.6 Cl-106 HCO3-23 AnGap-20 ___ 02:55PM BLOOD ALT-49* AST-36 AlkPhos-114* TotBili-0.7 ___ 02:55PM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.2 Mg-2.0 ___ 02:55PM BLOOD ___ ___ 02:55PM BLOOD cTropnT-0.41* ___ 11:28PM BLOOD CK-MB-7 cTropnT-0.46* ___ 06:01AM BLOOD CK-MB-7 cTropnT-0.53* ___ 02:40AM BLOOD cTropnT-0.46* ___ 06:32PM BLOOD D-Dimer-897* ___ 11:36AM BLOOD %HbA1c-5.8 eAG-120 ___ 06:01AM BLOOD Triglyc-117 HDL-29 CHOL/HD-7.0 LDLcalc-151* ___ 01:10PM BLOOD TSH-0.87 ___ 03:01PM BLOOD Lactate-2.0 DISCHARGE LABS ECG (___): Sinus rhythm. Short run of non-sustained atrial tachycardia. Delayed R wave progression. Cannot exclude anteroseptal myocardial infarction of indeterminate age. Borderline diagnostic inferior Q waves. No previous tracing available for comparison. Rate PR QRS QT QTc P QRS T 120 131 92 ___ 0 Transesophageal Echocardiogram ___: The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the inferior wall and hypokinesis of the distal half of the septum and anterior walls and apex. The apex is mildly aneurysmal and severely hypokinetic. The remaining segments contract normally (biplane LVEF = 31 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic valve leaflets are mildly thickened (?#). There is no valvular aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with extensive regional systolic dysfunction most c/w multivessel CAD or other diffuse process. Moderate to severe mitral regurgitation. Mild pulmonary artery systolic hypertension. Cardiac Catheterization ___: Dominance: Right LMCA: 25% ostial plaque. There was some dampening of the pressure waveform as the JL-3.5 catheter did not sit coaxially in the LMCA. LAD: proximal and mid LAD were calcified. The proximal LAD had mild plaquing and supplied a very high large ___ diagonal branch followed by very large, branching ___ septal. The LAD tapered abruptly after S1 into a tubular partially recanalized total occlusion; the distal and mid LAD filled retrogradely back from the apex via left-to-left collaterals. The long D1 was diffusely diseased to 40% proximally, 50% mid vessel, and 65% mid-distally. There was dynamic kinking of the mid portion of D1. Ramus intermedius: tortuous with dynamic rocking mid vessel before a prominent bifurcation. LCX: eccentric 40% origin stenosis. OM1 was tiny. There was a 60% mid LCX lesion. OM2 was of modest caliber. The branching OM3/LPL1 was of modest caliber with diffuse disease in the major LPL pole. The terminal AV groove CX was diminutive. RCA: focally calcified, ostial 70% stenosis arising before the conus branch. The proximal RCA had a 90% stenosis at the ___ AM/RV branch. The mid RCA had an 80% stenosis after the larger tortuous ___ AM/RV branch. The distal RCA had a tubular 75% stenosis. The RPDA had diffuse mild plaquing. RPL1 was a modest caliber vessel arising just before RPL2. RPL2 was a large and long vessel. The distal AV groove RCA terminated abruptly after RPL3 and a nodal branch, suggestive of a stump total occlusion. Pulmonary Function Tests ___ MECHANICS: The FVC and FEV1/FVC ratio are moderately reduced. The FEV1 is severely reduced. FLOW-VOLUME LOOP: Severely reduced flows overall with a moderately reduced volume and mild expiratory coving. LUNG VOLUMES: The TLC is normal. The FRC, RV and RV/TLC ratio are elevated. DLCO: The diffusing capacity corrected for hemoglobin is mildly to moderately reduced. Impression: Severe obstructive ventilatory defect with evidence of gas trapping. The reduced DLCO suggests an emphysematous process. There are no prior studies available for comparison. Chest CT ___ Very proximal ascending aorta and aortic arch are heavily affected by calcifications with sparing of the distal ascending aorta. Multiple nodules versus multifocal infectious process. Reassessment of the patient in 3 months is required. Bibasalar areas of atelectasis that potentially might represent infectious process. Severe emphysema. Echocardiogram ___ The left atrial volume index is mildly increased. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior and mid-distal anterior akinesis (multivessel CAD). There is an apical LV aneurysm. The remaining segments contract normally (LVEF = ___. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w multivessel CAD. Apical LV aneurysm. Moderate to severe mitral regurgitation. Transesophageal Echocardiogram (intraoperative) ___ PRE BYPASS The left atrium is mildly dilated. Small PFO with left-to-right shunt across the interatrial septum is seen at rest. There are simple atheroma in the aortic arch. There are complex (mobile) atheroma in the descending aorta. There are complex (>4mm) atheroma in the abdominal aorta. The LV is markedly dilated with preserved function only at the base. EF is ___. Takotsubo appearance. An apical clot cannot be excluded. RV function is preserved. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Dr. ___ findings. Post-Bypass #1: The patient has a significant sewing ring leak near P3 which required return to CPB and replacement. POST Bypass #2: The patient is on high doses of inotropes. LV is severely depressed. There is a mitral prosthesis with no leak and no MR. ___ intact. Transthoracic Echocardiogram ___ The left atrium is mildly dilated. There is moderate to severe regional left ventricular systolic dysfunction with akinesis of the inferior wall, distal septum and apex. The mid septum is hypokinetic as is the distal anterior wall. There is an apical left ventricular aneurysm. The remaining segments contract normally (LVEF = 30%). The right ventricular cavity is unusually small with normal free wall contractility. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a gradient across the RVOT likley due to the small size of the right ventricle with normal to hyperdynamic systolic function. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___ a bioprosthetic mitral valve is in place and is functioning normally. An RVOT gradient is seen. Mild differences in regional left ventricular systolic dysfunction may be due to abnormal septal motion post-CABG. Transthoracic Echocardiogram ___ A 1.2x1.7 cm echobright, somewhat mobile, round mass is seen in the left atrium (actual attachment not clearly defined, but appears to be the posterior left atrial wall), which may represent thrombus vs. other type of mass (it is not in location for warfarin ridge). There is severe regional left ventricular systolic dysfunction with severe hypokinesis of the anteroseptum and anterior wall and distal left ventricle, and akinesis of the basal-mid inferior wall. The remaining segments contract normally (LVEF = ___ %). There is an apical left ventricular aneurysm with a 1.0x0.8 cm spherical mass of moderate echo density within the aneurysm, typical in appearance for thrombus. The mass is mildly mobile within the aneurysm. Right ventricular chamber size is normal with borderline free wall hypokinesis. The aortic valve is not well seen. A bioprosthetic mitral valve prosthesis is present with elevated transvalvular gradients at a high heart rate (~130 bpm) Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There is a very small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of ___, two echodensities in the left atrium and left ventricle are identified ___ was seen in prior TTE; imaging was insufficient to evaluate LV aneurysm in that study). ___ was not appreciated on the ___ or ___ TTE, but the echodensity within the LV aneurysm was seen on review of ___ TTE. A very small pericardial effusion is also now seen. The mitral valve gradient is elevated, but at an elevated heart rate (vs prior TTE, HR 72 bpm with normal gradient). Biventricular systolic function appears similar. Abdomen/Pelvis CT ___ 1. No acute process within the abdomen or pelvis. 2. Thickened endometrium may represent fluid within the endometrial canal in the setting of mild cervical stenosis. Recommend non-urgent pelvic ultrasound for further evaluation. 3. Fibroid uterus. Chest CT ___ Extensive deep venous thrombosis in the right internal jugular, subclavian and axillary veins as well as in the left subclavian and axillary veins. Hyperdense and loculated retro and sub cardiac pericardial effusion measuring 20 mm in the craniocaudal plane as described above, suggestive of complex fluid from hemorrhage and less likely infection. Further investigation with cardiac echo advised. Left ventricular apical thrombus. Large loculated left-sided pleural effusion. Multifocal peribronchiolar nodular airspace opacification may be in keeping with early infection. Focused Transthoracic Echocardiogram ___ Overall left ventricular systolic function is moderately depressed with dyssynchrony (LVEF= 35 %). Right ventricular chamber size is normal with moderate global free wall hypokinesis. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion adjacent to the left ventricle and is not seen adjacent to the right heart. There are no echocardiographic signs of tamponade. Suboptimal image quality. Prior echo images of ___ unavailable for review for comparison of the appearance and size of the pericardial effusion. Upper Extremity Venous Ultrasound ___ No additional upper extremity deep venous thrombosis, other than findings from recent CT scan on ___. Lower Extremity Venous Ultrasound ___ 1. No evidence of deep venous thrombosis in the imaged bilateral lower extremity veins. 2. The right peroneal veins were not identified. Transthoracic Echocardiogram ___ seen in the right atrium or right atrial appendage. LV systolic function appears depressed. No masses or thrombi are seen in the left ventricle. There are complex (>4mm with mobile components) atheroma in the descending thoracic aorta to 35 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No vegetations or abscess.No aortic regurgitation is seen. A well-seated biologic mitral valve prosthesis is seen. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis. No mass or vegetation is seen on the mitral valve. No perivalvular abscess is seen. Trivial mitral regurgitation is seen. There is a moderate sized organized pericardial effusion inferior to the left ventricle and extending to the right ventricular free wall. The effusion appears organized with stranding. There are no echocardiographic signs of tamponade. IMPRESSION: Well seated bioprosthetic mitral valve with normal gradient. No definite masses, vegetations or abscess identified. Moderate size, loculated pericardial effusion without echocardiographic evidence of tamponade. Lipomatous hypertrophy without intraatrial thrombus identified. ___ Successful placement of a 25 cm tip to cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. . ___ 03:35AM BLOOD WBC-14.0* RBC-2.25* Hgb-6.6* Hct-22.9* MCV-102* MCH-29.3 MCHC-28.8* RDW-17.1* RDWSD-62.0* Plt ___ ___ 03:35AM BLOOD ___ PTT-69.3* ___ ___ 03:35AM BLOOD Glucose-105* UreaN-35* Creat-1.7* Na-131* K-4.7 Cl-97 HCO3-24 AnGap-15 ___ 03:35AM BLOOD ALT-24 AST-20 LD(LDH)-346* AlkPhos-107* Amylase-162* TotBili-0.4 ___ 03:35AM BLOOD Lipase-178* ___ 05:13AM BLOOD CK-MB-<1 cTropnT-0.26* ___ 03:35AM BLOOD Albumin-3.0* Calcium-9.7 Phos-3.1 Mg-2.2 ___ 10:29AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:29AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD Urine URINE CULTURE (Final ___: KLEBSIELLA OXYTOCA. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA \| AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ CXR Comparison to ___. The monitoring and support devices are stable. The diffuse parenchymal opacities, dominating in the right upper and right lower lung, are stable in extent and severity. Moderate cardiomegaly with retrocardiac atelectasis. No pneumothorax. Brief Hospital Course: Presented with acute respiratory failure with hypoxemia in acute systolic heart failure on bipap. She was give diuretics and underwent evaluation including cardiac catheterization that revealed coronary artery disease, echocardiogram that revealed mitral regurgitation and cardiac surgery was consulted. She was managed medically from admisision until ___ when she was taken to the operating room for coronary artery bypass graft and mitral valve replacement which was a complicated OR case. Please defer to operative report for further details. Post operatively she was taken to the intensive care unit for management on multiple pressors and inotropes. She had a prolonged recovery and is being discharged to rehab on post operative day forty. Acute encephalopathy felt to be multifactorial related to metabolic abnormalities and medications. Her medications have been adjusted and she continues to do well on Seroquel for sleep. She is awake and interactive Thrombocytopenia which was due to pump run and bleeding. HITT was checked ___ which was negative. However she dropped her platelets again with new clot noted in the subclavian bilateral and right internal jugular that was new even though she was on anticoagulation. Hematology was consulted, she was changed to argatroban. Repeat HITT ___ was negative and based on hematology evaluation they ruled her out for HITT. Her platelets have trended back up and have been stable. CT scan ___ revealed Extensive deep venous thrombosis in the right internal jugular vein surrounding the catheter and bilateral subclavian veins, Patchy nodular opacities in the inferior left upper lobe new from ___, and suspicious for infection.Severe centrilobular emphysema. Bilateral pleural effusions, small on the right, and loculated on the left, also new.New small/moderate hyperdense pericardial effusion, consistent with complex fluid such as blood. Multiple mediastinal lymph nodes, the largest measuring up to 13 mm in the right lower paratracheal station likely reactive. She had lower and upper extremities ultrasounds which did not reveal any other areas of clots and she remains on anticoagulation. Anemia Acute blood loss and acute illness and potential for chronic disease however due to multiple transfusions unable to check Iron studies at this time would recommend considering in the future. She received multiple transfusions however has remained stable with last transfusion ___ with hemodialysis. Acute Renal failure with potential chronic kidney disease as preoperatively mild increase in creatinine but no data available prior to admission. She was noted for acute kidney injury prior to surgery in combination with diuresis. Post operatively it was monitored but then she became anuric with significant volume overload. Renal was consulted and was started on CRRT ___. She continued on CRRT with volume removal and also to correct metabolic acidosis related to renal failure. On ___ she had tunnel line placed and was transitoned to hemodialysis. At this time her kidneys are recovering and she is diuresing on her own but then became oliguric and restarted HD with last dialysis ___ Leukocytosis with no clear etiology. She had fevers and was pan cultured multiple times. Infectious disease was consulted and based on no positive cultures and no indications from scan of infection she completed 14 course of cefepime and vanomycin for assumed ventilator pneumonia however sputum was only positive for yeast. After antibiotics stopped white blood cell progressively trended down. Then it increased and urine culture revealed Klebsiella sensitive to cipro placed on ___ompletes ___. Acute on Chronic respiratory failure with acute pulomonary edema, pleural effusion, and chronic obstructive pulmonary disease which she was still smoking up until admission. Preoperatively she required bipap due to the severity of hypoxia until she was diuresed. Post operatively she has remained on the ventilator and attempts to wean complicated by pleural effusions. Left chest tube placed ___ and right pigtail ___. Volume removal also with CRRT. She had bronchoscopy ___ that showed very inflamed airways but no evidence of infection. She continues to be weaned from the ventilator and attempts for trach collar. At the time of discharge she is on ___ 40% TV in mid ___ on CPAP to rest and tolerating trach collar for ___ minutes once a day She initially presented to the hospital in acute systolic heart failure with biventricular failure. She was managed medically but valve disease and coronary disease were contributing. After her surgery she required multiple pressors and inotropes including levophed, milirone, epinephrine, neosynephrine and vasopressin for support. Over multiple days they were weaned down but she required them for an extended period post operatively. She had multiple echocardiograms and was weaned off all drips except levophed for blood pressure support. Due to pressor requirement she was started on midodrine and was not able to tolerate ace inhibitor and contraindicated due to acute kidney injury. On echocardiogram ___ EF was estimated at 35%. Pericardial effusion noted on echocardiogram with no evidence of tamponade last echocardiogram ___ and no increase in size, no intervention indicated at this time. Hyponatremia which has been multifactorial including related to vasopressin. In additional renal and volume status at this time minimizing free water and monitoring. Has remained stable at 130-132. Atrial fibrillation with rapid ventricular rates treated with amiodarone initially as due to pressor requirement would not tolerate betablockers. She was additionally treated with digoxin however due to acute kidney injury it was stopped. As she remained off of pressors betablockers were added and she remains currently in sinus rhythm She continues on Coumadin for anticoagulation Due to respiratory failure requiring tracheostomy a PEG was placed for nutritional support. High residuals were noted and a KUB was done. It revealed nonspecific, nonobstructive bowel gas pattern favoring ileus. She was placed on reglan and should continue for gastric motility and is tolerating tube feeds noted for mild Amylase and lipase elevation with no abdominal discomfort. She remains stable with very slow progression. She was cleared for discharge to rehab at ___. Medications on Admission: Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q4H:PRN Pain - Mild 2. Albuterol Inhaler ___ PUFF IH Q6H 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheezing 4. Amiodarone 200 mg PO DAILY 5. Aspirin 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 6. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Doses 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate 110mcg 2 PUFF IH BID 10. Ipratropium Bromide MDI 6 PUFF IH Q6H 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN while on trach collar 12. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 13. Metoclopramide 5 mg PO Q6H Duration: 5 Days 14. Midodrine 15 mg PO TID 15. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all dressing changes 16. Polyethylene Glycol 17 g PO DAILY 17. QUEtiapine Fumarate 25 mg PO QHS 18. QUEtiapine Fumarate 12.5 mg PO BID:PRN anxiety 19. Sodium CITRATE 4% 2 mL DWELL PRN catheter not in use 20. ___ MD to order daily dose PO DAILY16 next INR ___ goal INR ___ for atrial fibrillation and subclavian and IJ clots 21. Multivitamins 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Coronary artery disease s/p coronary revascularization Mitral regurgitation s/p mitral valve replacement Acute encephalopathy felt to be multifactorial Thrombocytopenia Anemia Acute blood loss and acute illness and potential for chronic disease Acute Renal failure with potential chronic kidney disease Leukocytosis with no clear etiology Acute on Chronic respiratory failure with acute pulomonary edema, pleural effusion, and chronic obstructive pulmonary disease Acute systolic heart failure with biventricular failure Pericardial effusion Hyponatremia Atrial fibrillation with rapid ventricular rates Tobacco habituation Chronic obstructive pulmonary disease Urinary tract infection Discharge Condition: Alert and nods yes/no non-focal Deconditioned- max assistance Sternal pain managed with acetaminophen Sternal Incision - healing well, no erythema or drainage EVH - healing well, no erythema or drainage Discharge Instructions: Please wash daily including incisions with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Please weigh daily Monitor temperature daily and prn No driving No lifting more than 10 pounds for 10 weeks from surgery Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___
19836972-DS-13	19,836,972	20,014,283	DS	13	2158-02-26 00:00:00	2158-02-26 12:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: ___ Cardiac cath with IABP placement ___ Urgent coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery; and saphenous vein grafts to diagonal #1, diagonal #2, and obtuse marginal arteries. History of Present Illness: Mr. ___ is a ___ year old man with a history of atrial fibrilaltion and hypertension. He presented to ___ with complaints of ___ chest and left jaw pain. He ruled in for for myocardial infarction. He was transferred to ___ for cardiac catheterization which was significant for an ejection fraction of 40% and multivessel coronary disease. Prophylactic IABP was placed. Cardiac surgery consulted for revascularization evaluation. Past Medical History: CAD Hypertension Atrial fibrillation (no Coumadin since ___ Pernicious anemia Depression Past Surgical History: circumcision ___ d/t recurrent balanoposthitis), Right inguinal hernia repair (___), vasectomy Social History: ___ Family History: Paternal family significant for early CAD. Maternal history significant for diabetes, hypertension. Physical Exam: Admission Physical: Pulse: 63 SR Resp: 15 O2 sat: 96%3L B/P Right: Left: 126/70 Height: 67in Weight: 90.7kg General: NAD, supine w IABP Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _none_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: IABP Left:2+ DP Right: 2+ Left:2+ ___ Right: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: no bruits Discharge Physical: Pulse: 85, Afib Resp: 18 O2 sat: 100% on RA B/P: 111/73 Height: 67in Weight: 86.6kg General: NAD, WDWN, elderly man Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally with decreased bases, L>R [x] Heart: RRR [] Irregular [x] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: trace RLE, 1+ LLE with healing ecchymoses R groin, LLE ankle to groin (EVH leg), and LUE circumferential at PICC site, but PICC insert site is C/D/I Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ ___ Right: 2+ Left:2+ Radial Right: 2+ Left:2+ Pertinent Results: Stress Mibi ___ 1. Small inferior apical infarct without ischemia. 2. Inferior apical low septal hypokinesis. 3. Calculated global ejection fraction 42% CARDIAC CATHETERIZATION ___: Coronary angiography: right dominant LMCA: normal LAD: 90% proximal, 99% Branching large diag LCX: 50% mid, 90% OM1, 100% OM2 (LPL) RCA: occluded mid, fills by collaterals TTE ___: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses are normal with top normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferolateral wall and mid inferior wall and distal lateral and septal walls. The apex is akinetic. The remaining segments contract normally (LVEF = 40-45 %). The estimated cardiac index is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Top normal left ventricular cavity size with regional systolic dysfunction c/w multivessel CAD. Mild pulmonary artery hypertension. Mildly dilated ascending aorta. . Intra-op TEE ___ Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 45 - 50 %) with mild inferior, infero-aseptal and posterior HK. There is mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. The tip of the SGC is at the PA bifurcation. An IABP is in good position just beyond the left subclavian artery. Post-CPB The patient is in SR, on no inotropes. Unchanged biventricular systolic fxn. Trace AI. Trace MR. ___ intact. The IABP position is unchanged. . ___ 05:14AM BLOOD WBC-12.4* RBC-3.20* Hgb-9.9* Hct-30.7* MCV-96 MCH-31.1 MCHC-32.3 RDW-14.3 Plt ___ ___ 05:14AM BLOOD ___ ___ 04:37AM BLOOD ___ PTT-33.6 ___ ___ 03:06AM BLOOD ___ ___ 05:14AM BLOOD Glucose-113* UreaN-33* Creat-1.1 Na-141 K-4.1 Cl-106 HCO3-26 AnGap-13 ___ 04:37AM BLOOD Glucose-117* UreaN-31* Creat-1.2 Na-140 K-4.0 Cl-105 HCO3-27 AnGap-12 ___ 08:50AM BLOOD WBC-15.3* RBC-2.65* Hgb-8.2* Hct-25.6* MCV-97 MCH-30.9 MCHC-32.0 RDW-14.2 Plt ___ ___ 08:50AM BLOOD ___ PTT-34.4 ___ ___ 08:50AM BLOOD Glucose-153* UreaN-31* Creat-1.1 Na-140 K-4.1 Cl-105 HCO3-25 AnGap-14 ___ 10:33AM BLOOD %HbA1c-5.8 eAG-120 Micro: ___ 4:31 pm URINE Source: ___. *FINAL REPORT ___ URINE CULTURE (Final ___: SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Following cardiac catheterization, Mr. ___ was admitted and underwent surgical work-up. On the following day he was brought to the operating room where he underwent an urgent coronary artery bypass graft x4:Left internal mammary artery to left anterior descending artery; and saphenous vein grafts to diagonal #1, diagonal #2, and obtuse marginal arteries. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. POD 1 found the patient extubated, alert and oriented and breathing comfortably. Intra-aortic balloon pump was removed on POD1 without complication and with subsequent stable hemodynamics. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Left lower extremity JP drain was pulled with minimal drainage. Chest tubes were removed per cardiac surgery protocol with no pneumothorax on post pull CXR. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Patient went into rapid atrial fibrillation on POD #1, which was difficult to rate control and delayed his dischage for several days. He was given IV beta blockers, a diltiazem drip and amiodarone bolus and drip. EP was consulted for further assistance (___). He was rate controlled at the time of discharge, on amiodarone, diltiazem, and lopressor, with accepting resting HR of 110. Per EP recommendations, he will taper amiodarone on ___ to 200mg po daily. Coumadin was initiated with goal INR ___. Pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. A Left arm, double lumen, power-PICC line (46cm) was placed on ___ due to poor peripheral IV access. His foley catheter was replaced once postoperatively, but he then voided without troubles following second removal. Urine culture sent ___ grew Serratia marcescens, and he will have 3 day course of Ciprofloxacin 500mg po BID, starting ___. He has no complaints of dysuria, but will need a follow up CBC on WED, ___ to confirm improved WBC (15.4 today). By the time of discharge on POD #12 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to ___ in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Triamterene 37.5 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Cyanocobalamin 50 mcg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Naproxen 500 mg PO Q12H 6. Vitamin D ___ UNIT PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Glucosamine (glucosamine sulfate) 500 mg oral daily 9. chondroitin sulfate A 250 mg oral daily Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Amiodarone 400 mg PO BID x 1 days then decrease to 200mg daily (decrease starting ___ 3. Atorvastatin 80 mg PO DAILY 4. Bisacodyl ___AILY:PRN constipation 5. Diltiazem 60 mg PO TID (hold for SBP<90 or HR<55) 6. Docusate Sodium 100 mg PO BID 7. Metoprolol Tartrate 100 mg PO TID hold for HR <55 or SBP <95 8. Milk of Magnesia 30 ml PO DAILY 9. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days 10. Ranitidine 150 mg PO DAILY 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX tramadol [Ultram] 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 12. ___ MD to order daily dose PO DAILY16 postop AFib 13. Warfarin 0.5 mg PO ONCE Duration: 1 Dose for today ___ (INR 2.3 today) 14. chondroitin sulfate A 250 mg oral daily 15. Citalopram 20 mg PO DAILY 16. Cyanocobalamin 50 mcg PO DAILY 17. Glucosamine (glucosamine sulfate) 500 mg oral daily 18. Multivitamins 1 TAB PO DAILY 19. Vitamin D ___ UNIT PO DAILY 20. Furosemide 20 mg PO DAILY Duration: 5 Days 21. Ciprofloxacin 500mg po BID Duration: 3 Days, starting ___ (for UTI) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft Myocardial infarction Past medical history: Hypertension Atrial fibrillation (no Coumadin since ___ converted back to NSR) postop Atrial fibrillation postop Serratia UTI Pernicious anemia Depression Coronary artery disease s/p Coronary artery bypass graft Myocardial infarction Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage, upper thigh>lower leg ecchymosis (EVH leg) Right groin - healing well with groin ecchymosis, no drainage/erythema LUE PICC site - C/D/I with healing, minimal ecchymosis Edema - trace RLE, 1+ LLE Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___
19836972-DS-14	19,836,972	24,303,458	DS	14	2158-03-09 00:00:00	2158-03-09 14:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ - ERCP/Cholangiogram History of Present Illness: ___ yo male s/p Urgent coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery; and saphenous vein grafts to diagonal #1, diagonal #2, and obtuse marginal arteries. Post op course complicated by refractory rapid atrial fibrillation which was difficult to control. At the time of discharge, his atrial fibrillation was rate-controlled with beta-blocker, diltiazem, amiodarone and coumadin. At that time, he also had serratia UTI. He was discharged home on POD 12 to ___. He was discharged from rehab to home on ___. Per wife, patient on the morning of ___ complaining of diffuse chest pain and chills. By the time EMS arrived, patient reported pain had become migrated to right lower abdominal region, radiating to right flank. No fevers noted, he had otherwise been doing well at home. Vomited en route to ED. At the time of admission to ___ ED, he noted right sided pain, ___, dull, nonradiating associated with Nausea/vomiting. He was admitted for further evaluation and treatment. Past Medical History: 1) CAD 2) Hypertension 3) Atrial fibrillation (no Coumadin since ___ 3) Pernicious anemia 4) Depression Past Surgical History: 1) Circumcision ___ d/t recurrent balanoposthitis) 2) Right inguinal hernia repair (___), vasectomy Social History: ___ Family History: Paternal family significant for early CAD. Maternal history significant for diabetes, hypertension. Physical Exam: PHYSICAL EXAM ON ADMISSION: Pulse:AF 130-150 Resp:22 O2 sat: 98% RA B/P Right: 114/59 Left: Height: 5'7" Weight:190# General:AAOx 3 in mild distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] tachy Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds + [x] Right lower quadrant TTP Extremities: Warm [x], well-perfused [x] Edema 1+ LLE edema, saph site Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ ___ Right:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit - PHYSICAL EXAM ON DISCHARGE: Pulse:NSR 54-62 bpm Resp:18 O2 sat: 99% RA B/P Right: ___ Height: 5'7" Weight:90.1 k General:AAOx 3 in mild distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [X] Irregular [] tachy Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema 1+ LLE edema,saph site Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ ___ Right:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit - Pertinent Results: ___ 11:42AM LIPASE-181* ___ 11:42AM WBC-12.7* RBC-3.62# HGB-10.9# HCT-35.6# MCV-98 MCH-30.2 MCHC-30.7 RDW-14.5 ___ 05:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG . ___ CTA 1. No evidence of acute aortic pathology including no evidence of aneurysm or dissection. No pulmonary embolus. 2. Mild narrowing at the origin of the celiac artery without significant atherosclerosis, likely due to median arcuate ligament compression. 3. Moderately distended gallbladder with small amount of pericholecystic fluid along the hepatic edge. Ultrasound can be obtained for further evaluation. 4. Small left pleural effusion with associated atelectasis. Post-surgical changes after recent CABG. . ___ Ultrasound Gallbladder sludge without findings for acute inflammation. If clinical concern for acalculous cholecystitis is high then HIDA would be recommended. . ___ 06:45AM BLOOD WBC-11.2* RBC-3.03* Hgb-9.2* Hct-30.4* MCV-100* MCH-30.5 MCHC-30.4* RDW-15.0 Plt ___ ___ 07:40AM BLOOD WBC-6.4 RBC-2.94* Hgb-9.1* Hct-28.9* MCV-98 MCH-31.1 MCHC-31.6 RDW-15.0 Plt ___ ___ 05:18AM BLOOD WBC-4.6 RBC-3.06* Hgb-9.5* Hct-29.5* MCV-96 MCH-31.0 MCHC-32.1 RDW-15.3 Plt ___ ___ 08:00AM BLOOD WBC-4.2 RBC-3.41* Hgb-10.5* Hct-33.4* MCV-98 MCH-30.7 MCHC-31.4 RDW-14.9 Plt ___ ___ 08:00AM BLOOD ___ PTT-32.7 ___ ___ 05:18AM BLOOD ___ ___ 07:40AM BLOOD ___ PTT-50.7* ___ ___ 06:45AM BLOOD ___ ___ 03:05PM BLOOD ___ PTT-31.9 ___ ___ 08:00AM BLOOD Glucose-125* UreaN-17 Creat-0.9 Na-140 K-4.0 Cl-105 HCO3-27 AnGap-12 ___ 05:18AM BLOOD Glucose-100 UreaN-23* Creat-0.8 Na-142 K-3.7 Cl-108 HCO3-25 AnGap-13 ___ 07:40AM BLOOD Glucose-137* UreaN-27* Creat-0.9 Na-141 K-3.8 Cl-108 HCO3-24 AnGap-13 ___ 06:45AM BLOOD Glucose-136* UreaN-31* Creat-1.4* Na-140 K-4.2 Cl-107 HCO3-23 AnGap-14 ___ 11:42AM BLOOD Glucose-131* UreaN-26* Creat-1.0 Na-139 K-4.2 Cl-104 HCO3-21* AnGap-18 ___ 08:00AM BLOOD ALT-166* AST-44* LD(LDH)-222 AlkPhos-471* Amylase-107* TotBili-1.7* ___ 05:18AM BLOOD ALT-234* AST-80* LD(LDH)-194 AlkPhos-461* Amylase-95 TotBili-2.7* ___ 07:40AM BLOOD ALT-353* AST-152* LD(LDH)-213 AlkPhos-439* Amylase-80 TotBili-2.7* ___ 06:45AM BLOOD ALT-559* AST-480* LD(LDH)-293* AlkPhos-494* Amylase-100 TotBili-3.7* ___ 11:42AM BLOOD ALT-167* AST-320* AlkPhos-530* TotBili-1.5 ___ 08:00AM BLOOD Lipase-140* ___ 05:18AM BLOOD Lipase-104* ___ 07:40AM BLOOD Lipase-82* ___ 06:45AM BLOOD Lipase-62* ___ 11:42AM BLOOD Lipase-181* ___ 08:00AM BLOOD Albumin-2.8* Phos-2.5* Mg-2.0 ___ 05:18AM BLOOD Mg-2.2 ___ 07:40AM BLOOD Phos-2.0# Mg-2.2 ___ 06:45AM BLOOD Albumin-2.9 Calcium-8.2* Phos-3.6 Mg-1.9 ___ 11:42AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.5 Mg-2.0 ___ 08:28PM BLOOD Lactate-1.3 Brief Hospital Course: Mr. ___ was admitted to the ___ on ___ for further evaluation and management of his abdominal pain. He underwent a CT scan which showed moderately distended gallbladder with a small amount of pericholecystic fluid along the hepatic edge. Right upper quadrant ultrasound showed gall bladder sludge. He also had elevated liver function tests at the time of admission with a total bilirubin of 1.7. The general surgery service was consulted and an MRCP was planned. Blood culures came back positive with gram negative rods which speciated for serratia. UA was also positive and urine culture came back positive with coagulase negative staphylococcus. He was made NPO with got agressive IV hydration while MRCP was being planned. ERCP was planned given a jump in total bilirubin to 3.7 in the setting of acute cholangitis with gram negative bactermia. His INR at the time of admission was 2.2. This was corrected with transfusion of FFPs to safely perform his cholangiogram. On ___ an ERCP was done which showed no filling defects, Sphinc-terotomy done and balloon sweeps resulted in small amount of sludge extraction. He was transferred to the floor in hemodynamically stable condition and kept NPO overnight. On PPD 1, he was started on clear liquid diet and gradually advanced upto regular diet which he tolerated very well. He remained afebrile through his hospitalization and his white cell counts trended down to 4.2 at the time of discharge. A cholecystectomy was recommended which will be planned after an outpatient evaluation in the Acute Care Surgery clinic in ___ weeks. Coumadin was resumed. Since his HR remained in ___, diltiazem and beta blocker doses were titrated. He was discharged home with ___ on HD5 in a stable manner. Medications on Admission: 1. Aspirin EC 81 mg PO DAILY 2. Amiodarone 200 mg PO daily 3. Atorvastatin 80 mg PO DAILY 4. Diltiazem 60 mg PO TID (hold for SBP<90 or HR<55) 5. Lopressor 100 mg TID ___ MD to order daily dose PO DAILY16 postop AFib - ___ mg for INR 1.6 on ___ (followed by Dr. ___ 7. Citalopram 20 mg PO DAILY 8 Cyanocobalamin 50 mcg PO DAILY 9. Glucosamine (glucosamine sulfate) 500 mg oral daily 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY RX amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 3. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Citalopram 20 mg PO DAILY RX citalopram [Celexa] 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Diltiazem 30 mg PO TID RX diltiazem HCl 30 mg 1 tablet(s) by mouth three times a day Disp #30 Tablet Refills:1 6. Metoprolol Tartrate 50 mg PO TID RX metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #30 Tablet Refills:2 7. Warfarin 2 mg PO ONCE Duration: 1 Dose on ___ 8. Warfarin 1 mg PO ADDTL INSTRUCTIONS Dose based on INR. To be titrated daily by Cardiologist/PCP ___ warfarin [Coumadin] 1 mg 1 tablet(s) by mouth DOSE TO BE TITRATED DAILY Disp #30 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Choledocholithiasis Other: s/p CABGx4 Hypertension Atrial fibrillation (no Coumadin since ___ Pernicious anemia Depression Past Surgical History: circumcision ___ d/t recurrent balanoposthitis), Right inguinal hernia repair (___), vasectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving until further follow-up at Cardiac Surgery office. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns ___ Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___
19836972-DS-15	19,836,972	25,283,018	DS	15	2158-03-28 00:00:00	2158-03-28 19:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Oxycodone Attending: ___ Chief Complaint: right upper quadrant pain Major Surgical or Invasive Procedure: ___ percutaneous cholecystotomy tube History of Present Illness: This patient is a ___ year old male who complains of Abd pain. Patient presented right upper quadrant pain started today. Describes the pain as sharp. He rates the pain ___. Patient went outside hospital an ultrasound showed biliary sludge. Of note patient had similar presentation two weeks ago. At that time patient was recently status post CABG and surgery elected not to operate. Patient denies any fevers or chills. Patient reports having nausea and vomiting. Past Medical History: 1) CAD 2) Hypertension 3) Atrial fibrillation (no Coumadin since ___ 3) Pernicious anemia 4) Depression Past Surgical History: 1) Circumcision ___ d/t recurrent balanoposthitis) 2) Right inguinal hernia repair (___), vasectomy Social History: ___ Family History: Paternal family significant for early CAD. Maternal history significant for diabetes, hypertension. Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 98.6 HR: 73 BP: 149/94 Resp: 14 O(2)Sat: 96 Constitutional: Comfortable HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: RUQ tenderness, no rebound, minimal guarding Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent Physical examination upon discharge: ___: vital signs: t=99, hr=66, bp=138/82, rr=18, oxygen sat=94% room air HEENT: sclera anicteric CV: ns1, s2, -s3, -s4 LUNGS: crackles bases bil ABDOMEN: soft, mild tenderness right upper quadrant, right abdominal drain with DSD, blood tinged bilous drainage EXT: + dp bil., pedal edema +1 bil., no calf tenderness bil. NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 06:34AM BLOOD WBC-8.5 RBC-3.48* Hgb-10.7* Hct-33.8* MCV-97 MCH-30.8 MCHC-31.8 RDW-15.6* Plt ___ ___ 06:00AM BLOOD WBC-5.8 RBC-3.18* Hgb-9.9* Hct-31.1* MCV-98 MCH-31.1 MCHC-31.8 RDW-15.6* Plt ___ ___ 01:10PM BLOOD WBC-13.9# RBC-4.11 Hgb-12.7* Hct-39.7* MCV-97 MCH-31.0 MCHC-32.1 RDW-15.4 Plt ___ ___ 01:10PM BLOOD Neuts-83.8* Lymphs-9.0* Monos-6.6 Eos-0.3 Baso-0.4 ___ 06:10AM BLOOD ___ ___ 06:34AM BLOOD Plt ___ ___ 06:34AM BLOOD ___ PTT-38.8* ___ ___ 06:34AM BLOOD Glucose-125* UreaN-22* Creat-0.8 Na-137 K-3.5 Cl-100 HCO3-27 AnGap-14 ___ 01:10PM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-138 K-3.6 Cl-105 HCO3-21* AnGap-16 ___ 06:00AM BLOOD ALT-28 AST-24 AlkPhos-111 TotBili-0.9 ___ 06:10AM BLOOD Lipase-26 ___ 01:10PM BLOOD Lipase-71* ___ 06:34AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.1 ___ 04:44PM BLOOD Lactate-2.4* ___: chest x-ray: No evidence of acute cardiopulmonary process given low lung volumes. ___: Lower ext US: No evidence of a right lower extremity deep vein thrombosis. ___: liver/gallbladder US: . No cholelithiasis, though the gallbladder had a moderate amount of sludge, wall thickening, and wall edema. There is a positive sonographic ___ sign. Together, these findings may be compatible with acalculous acute cholecystitis in the proper clinical setting. If further characterization is required, could consider a HIDA scan. 2. Trace perihepatic fluid ___: gallbladder drainage: Technically successful ultrasound-guided percutaneous cholecystostomy with placement of an 8 ___ ___ catheter. Brief Hospital Course: The patient was admitted to the hospital with right upper quadrant pain. He was noted to have an elevated white blood cell count and a mild elevation in the alkaline phosphatase. Upon admission, the patient was made NPO, given intravenous fluids and underwent imaging. An ultrasound of the gallbladder was done which showed gallbladder sludge, thickening and wall edema. There was a mild elevation in the patient's INR and he was given a unit of fresh frozen plasma to prepare the patient for drain placement. Because of the patient's recent history of cardiac surgery, the patient was taken to ___ for placement of a drain into the gallbladder with the aspirate of 40cc of red-tinged bloody bile. The patient tolerated the procedure and had a mild resolution of his pain. His liver function tests normalized The bile culture grew serratia and gram negative rods which were reported to be sensitive to bactrim. The patient's ciprofloxacin and flagyl were discontinued and the patient was started on a five day course of bactrim. The patient resumed his Coumadin on HD #2 and daily dosing was resumed based on the patient's daily ___. The patient resumed a regular diet and his vital signs remained stable. His white blood cell count had normalized. He resumed his home medications. He was discharged home in stable condition on HD # 4 with ___ services for assistance with drain care and monitoring of his INR. Follow-up appointments were made with the acute care service and with his Cardiologist. Medications on Admission: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Diltiazem 30 mg PO TID 6. Metoprolol Tartrate 50 mg PO TID 7. Warfarin daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Diltiazem 30 mg PO TID 6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 hours Disp #20 Tablet Refills:0 7. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days last dose ___ RX sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #11 Tablet Refills:0 8. Aspirin 81 mg PO DAILY 9. Warfarin 2 mg PO ONCE Duration: 1 Dose please give at 4pm ___.. daily dosing as per daily INR 10. Metoprolol Tartrate 50 mg PO TID 11. Docusate Sodium 100 mg PO BID hold for diarrhea 12. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ ___: cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ were admitted to the hospital with right upper quadrant pain. ___ underwent an special test called an ERCP and ___ were found to have sludge in your gallbladder. Because of your recent cardiac surgery, ___ underwent placement of a drain into the gallbladder with a plan of removing your gallbladder in ___ weeks. Your vital signs have been stable. ___ are preparing for discharge with the following instructions: ___ will be discharged with the drain in place: General Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation Please call your doctor or return to the emergency room if ___ have any of the following: * ___ experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If ___ are vomiting and cannot keep in fluids or your medications. * ___ are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * ___ see blood or dark/black material when ___ vomit or have a bowel movement. * ___ have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern ___. * Please resume all regular home medications and take any new meds as ordered Followup Instructions: ___
19837155-DS-6	19,837,155	25,205,606	DS	6	2152-12-24 00:00:00	2153-01-03 09:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Retroperitoneal free air with tracking into the mediastinum Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with history of Hep C and Billroth II who presents to the ED with worsening abdominal pain associated with fever. Earlier today, patient underwent upper endoscopy with EUS and biopsy of GJ anastomosis and small bowel for work up of diarrhea, chronic CBD dilation, and possible pancreatic lesion (according to wife). Patient went home post-procedure and developed worsening abdominal pain and had temperature of 103. He called Dr. ___ and was directed to the ED where CT showed retroperitoneal free air with tracking into the mediastinum for which surgery is consulted. On evaluation, patient continues to endorse abdominal pain with subjective fevers. Denies chills, nausea, vomiting, chest pain, SOB, cough. Past Medical History: - Hepatitis C status post successful treatment with pegylated interferon and ribavirin in ___. He is PCR negative as of ___ this year - Gout - H. pylori, upper GI bleed Social History: ___ Family History: non-contributory Physical Exam: VS - 99.4, 93, 115/72, 24, 95% RA GEN: NAD, non-toxic HEENT: no scleral icterus, moist mucous membranes CV: RRR PULM: CTAB, breathing comfortably on room air ABD: firm, mildly tender, non-distended, no guarding or rebound EXT: warm, well-perfused, no edema Pertinent Results: ___ 05:16AM BLOOD WBC-9.8 RBC-3.52* Hgb-11.1* Hct-33.3* MCV-95 MCH-31.5 MCHC-33.3 RDW-14.1 RDWSD-48.9* Plt ___ ___ 05:16AM BLOOD Glucose-140* UreaN-13 Creat-0.7 Na-135 K-3.9 Cl-103 HCO3-21* AnGap-15 ___ 11:20PM BLOOD ALT-18 AST-18 AlkPhos-58 TotBili-0.5 ___ 05:16AM BLOOD Calcium-7.4* Phos-1.9* Mg-2.1 Brief Hospital Course: Mr. ___ was admitted to the ___ surgical service on ___ for evaluation and treatment of free retroperitoneal with tracking into the mediastinum of unclear etiology. A CT scan done on ___ in the emergency room showed focal extraluminal contrast versus artifact at the GE junction, just proximal to an area of mild esophageal wall thickening. It further showed redistribution of extensive retroperitoneal free air, predominantly in the right upper retroperitoneum, and no intraperitoneal free air. A swallow study showed no evidence of esophageal perforation or leak of oral contrast. The patient arrived on the floor NPO, on IV fluids, and IV morphine for pain control. He was started on IV antibiotics (Vancomycin, Cefepime, Flagyl and Fluconazole). He remained afebrile and hemodynamically stable and was switched to PO pain medicication and PO Augmentin and Fluconazole. Adequate pain control was achieved with oral medication. His diet was advanced to clear liquids. The patient was able to ambulate and void without difficulty. On hospital day 2 the patient remained clinically stable and felt ready to return home. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a clear liquid diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Allopurinol Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth Q12 Disp #28 Tablet Refills:0 2. Fluconazole 400 mg PO Q24H RX fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth Q24 Disp #14 Tablet Refills:0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain Please take with food. Do not drink or drive when taking. RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4 Disp #40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Retroperitoneal free air with tracking into the mediastinum Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please slowly advance your diet at home from clears to a regular solid diet. Followup Instructions: ___

Subsets and Splits